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A TEXT-BOOK 



OF 



Operative Surgery 



COVERING THE SURGICAL ANATOMY AND 
OPERATIVE TECHNIC INVOLVED IN THE 
OPERATIONS OF GENERAL SURGERY 



DESIGNED FOR PRACTITIONERS AND STUDENTS 



BY 

WARREN STONE BICKHAM, M. D., Phar. M. 

Junior Surgeon, Touro Hospital. New Orleans ; late Surgeon to Manhattan State Hospital, New 

York; late Assistant Instructor in Operative Surgery, College of Physicians and Surgeons 

(Columbia University), New York ; late Instructor in Surgery, New York Post-Graduate 

Medical School and Hospital; late Instructor in Surgery, New York Polyclinic 

Medical School and Hospital ; late Yisiting Surgeon to Charity Hospital, 

New Orleans ; late Demonstrator of Operative Surgery, Medical 

Department, Tulane University of Louisiana, New Orleans ; 

Fellow of the New York Academy of Medicine, etc. 



THIRD EDITION, GREATLY ENLARGED 
CONTAINING 854 ILLUSTRATIONS 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1 908 



Set up, electrotyped, printed, and copyrighted August, 1903 Revised, reprinted, and recopyrighted 

April, 1904. Reprinted February, 1905, February, 1906, and September, 1906. 

Revised, reprinted, and recopyrighted September, 1908. 



Copyright, 1908, by W. B. Saunders Company. 



!ESS O F 

M O E RS COMP* 



IN REVERED MEMORY OF MY FATHER 

Cbarles Jasper 36icfebam 

WHOSE DAILY LIFE EMBODIED THE HIGHEST IDEALS OF CHRISTIAN 
PHYSICIAN, I LOVINGLY DEDICATE THIS WORK 



PREFACE TO THIRD EDITION. 



The scope of the alterations in this edition of the present work is suffi- 
ciently shown by the additions and omissions here indicated. 

The last edition of this work contained 984 pages, including 559 illustra- 
tions. 

The present edition contains 1204 pages, including 854 illustrations. 

In the new edition the following changes have been made from the old: 
29 pages of text, covering 25 operations, have been dropped; 123 pages of 
text, descriptive of 106 operations, have been added; 42 old pictures have 
been omitted; 45 old pictures have been redrawn; and 331 new pictures 
have been added. 

The Author especially desires to express his appreciation of the kindly 
reception of his efforts by the Profession — Surgical and Medical — as evi- 
denced by the demand for additional editions, and trusts that the recent 
changes and additions in the writings and illustrations will materially add 
to the general usefulness of the work. 

Deep gratitude is due the author's Wife for her constant aid throughout 
the work, and for her unfaltering encouragement during the many days of 
its preparation. 

The writer wishes to testify his sincere appreciation of the continuous 
and substantial aid given him by Mrs. Farnsworth, his Assistant, in the 
general work of revision, and especially in the drawing of considerably the 
larger number of the new pictures. 

Thanks are again extended to Miss Fry for those illustrations made by 
her. 

The liberality of the Publishers in arranging the details of the revision 
and the excellence of its execution are fully acknowledged. 

Finally, the writer desires to express his earnest esteem of the many 
valuable intellectual opportunities, and of the large practical contact with 
surgical work, resulting from the close professional and friendlv associate- 
ship with Professor Rudolph Matas, whose general surgical knowledge, 
marvelous in its extent and detail, is most probably not exceeded by that of 
any Surgeon living. 

W. S. B. 

New Orleans, September, 1908. 
3521 Prytania Street. 



PREFACE TO THE FIRST EDITION. 



The sub-title of the present volume sufficiently designates its intended 
scope — "The Surgical Anatomy and Operative Technic involved in the 
Operations of General Surgery." The work is planned to be a presentation 
to the Student and Practitioner of the best technic of modern Surgeons in 
the operations mentioned — accompanied by a brief summary of the descrip- 
tive and surgical anatomy of the structures involved. 

The clinical aspect of Operative Surgery has been less fully dealt with — 
and in generalizations in connection with groups of operations, rather than 
specifically in connection with individual operations. 

An apology for the amount of Anatomy given may seem, to some, neces- 
sary. From the standpoint of the pure technician, Operative Surgery is, 
largely, Applied Anatomy — the application of the facts of Surgical Anatomy 
during the progress of Surgical Manipulations — the resulting Operative 
Technic being more or less perfect as the knowledge of the Surgical Anatomy 
and the conduction of the Surgical Manipulations are more or less perfect. 
Theoretically, it is proper to expect fourth-year Students to come into the 
Operating Room with their Anatomy in an available form for surgical work 
— practically, this is rarely found — and is often absent in seasoned Operators. 

In the arrangement of this work the subjects have been grouped under, 
The Operations of General Surgery (Part I), and, The Operations of Special 
Surgery (Part II) — as further detailed in the especially full Contents. In 
dealing with each group of tissues, or class of operations (in Part I), or with 
each organ (in Part II), the following divisions of the subjects are taken up, 
in order:— (i) Surgical Anatomy (of the region or organ); (2) Surface Form 
and Landmarks; (3) General Surgical Considerations (in operating upon 
that region or organ) ; (4) Instruments (used in such operations) — all being 
introductory to the specific operations, — after which each operation is taken 
up in turn, under the following headings: — (1) Title of Operation; (2) De- 
scription of Operation (including its general indications); (3) Preparation 
of Patient; (4) Position of Patient, Surgeon, and Assistant; (5) Landmarks 
of Operation; (6) Incision for Operation; (7) Steps of Operation; (8) Com- 
ments. 

In the description of the technic of the operations the "Incision" is given 
a heading to itself — to emphasize the importance of this step of the operation 
— recognizing that the Operator who starts out aright is a long way ahead 
of the man who takes his initial step erroneously. Under "Operation" the 
various steps are given in numbered paragraphs — the different paragraphs 
usually indicating, in a general way, some change in the technic or in the 
stage of the operation. 

The Principles of Operative Surgery, and Anesthesia, as well as the 
Operations of Plastic Surgery, many of the operations more properly classed 
as the operations of Special Branches of Surgery, and some of the many 
variations of the operations of General Surgery, have been omitted. 



2 PREFACE. 

In the preparation of these pages, obligations are hereby gratefully and 
fully acknowledged to the writings of many well-known Surgeons in the 
standard works of the day upon Operative Surgery, and in the current surgical 
literature, whose pages have been freely consulted — and to the work of many 
Surgeons, here and abroad, whose operative technic it has been the privilege 
of the author to witness — and to writings upon Anatomy. 

The name of the deviser of an operation is given, in brackets, after the 
title of the operation, wherever known to the author. Where slight de- 
partures from the manner of doing the operation as performed by its originator 
occur, such omission is accidental — or, where the original description is 
ambiguous, the operation is given as it seems to be interpreted by the majority 
of Surgeons. 

Appreciation of encouragement shown during the preparation of the 
manuscript is gratefully acknowledged to Professors Bull, Dennis, Hal- 
sted, Hartley, Matas, Richardson, Senn, Weir, and Wyeth — and to my 
co-workers, Doctors Peck, Schmitt, and Taylor, in the Department of Op- 
erative Surgery at the College of Physicians and Surgeons — and to Doctor 
Gessner, my former co-worker in the Laboratory of Operative Surgery 
of Tulane University — and to Doctors Armstrong and LeBeuf — and to 
other friends whose kindly words have aided and lightened the work of 
preparation. 

The author feels deeply indebted to Miss Eleanora Fry, who has drawn, 
under his close directions, all the illustrations for the book, during many 
weeks of conscientious work and unflagging interest — the large majority of 
the five-hundred and fifty-nine illustrations being original, and the remainder 
so largely modified as to be, in many instances, practically new pictures. 

I wish to thank the Publishers for the courteous consideration they have 
shown my every expression of wish throughout — for their interest in the 
manuscript — and for the quality of their finished work. 

I desire to express my high valuation of my Wife's ever-ready and untiring 
aid in all the proof-readings of the manuscript during the many months 
of its preparation. 

The imperfections of the present work are very fully realized — and the 
author will be glad to receive all criticisms which may tend to the bettering 
of the text and illustrations. 



WARREN STONE BICKHAM. 



10 East 58TH Street, 
New York City. 



CONTENTS. 



PART I. 
THE OPERATIONS OF GENERAL SURGERY. 



CHAPTER I. 
OPERATIONS UPON ARTERIES. 

I. Ligation of arteries — General considerations, 17. 

II. Surgical Anatomy and Ligation of following Arteries of Head and Neck:— Innominate, 
by angular incision (Mott's operation), 27 — By oblique incision, 30 — By partial bony resection 
(Bardenheuer's operation), 31 — By splitting of manubrium sterni, 31 — Common carotid, above 
omohyoid, 34 — Below omohyoid, 35 — External carotid, below digastric, 37 — Above digastric, 
behind ramus of jaw, 38 — Lingual, near origin, 39 — Beneath hyoglossus, 39 — Facial, near 
origin, 41 — Over inferior maxilla, 41 — Occipital, near origin, 42 — Behind mastoid process, 
42 — Temporal, just above zygoma, 43 — Internal maxillary (surgical anatomy), 44 — Trunk 
of middle meningeal, in cranium, through trephine-opening exposed by curved oblique incision, 
47 — Anterior branch of middle meningeal, through trephine-opening exposed by horseshoe 
incision, 48 — Posterior branch of middle meningeal, through trephine-opening exposed by 
horseshoe incision, 49 — Internal carotid, near origin, 50 — First part of right subclavian, by 
angular incision, 52 — First part of left subclavian, by angular incision, 52 — Second part of 
subclavian, 53 — Third part of subclavian, 53 — Vertebral, near origin, 55 — Inferior thyroid, 57. 

III. Surgical Anatomy and Ligation of following Arteries of Upper Extremity and Thorax: 
— Internal mammary, in second intercostal space, 58 — First part of axillary, by curved trans- 
verse incision below clavicle, 60 — Third part of axillary, 62 — Brachial, in mid-arm, 64 — At 
bend of elbow, 65 — Radial, in upper third, 69 — In lower third, 70 — Deep palmar arch, 72 — 
Ulnar, in middle third, 74 — In lower third, 76 — Intercostal, by intercostal incision, 76 — Inter- 
costal, by partial subperiosteal excision of rib (Hartley's method), 78. 

IV. Surgical Anatomy and Ligation of following Arteries of Trunk: — Abdominal aorta, 
by transperitoneal method, 79 — By retroperitoneal method, 80 — Common iliac, by retroperitoneal 
method, Si — By transperitoneal method, 83 — Internal iliac, by retroperitoneal method, 84 — 
By transperitoneal method, 84 — Sciatic, upon buttock, 84 — Internal pudic, upon buttock, 87 — 
In perineum, 87 — Gluteal, on buttock, 87 — External iliac, by retroperitoneal method, 89 — By 
transperitoneal method, 91. 

V. Surgical Anatomy and Ligation of following Arteries of Lower Extremity: — Common 
femoral, at base of Scarpa's triangle, 93 — Profunda femoris, near origin, 95 — Superficial femoral, 
at apex of Scarpa's triangle, 96 — In Hunter's canal, 98 — Popliteal, in upper part of popliteal 
space, from behind, 100 — In upper part of popliteal space, from inner side of thigh, Jobert's 
operation, 100 — In lower part of popliteal space, 10 1 — Anterior tibial, in upper third, 104 — 
In middle third, 105 — In lower third, 105 — Dorsalis pedis, just below ankle-joint, 107 — Pos- 
terior tibial, in upper third, above peroneal branch, 109 — In middle third, no — In lower third, 
112 — Behind internal malleolus, 112 — Peroneal, in middle of leg, 114 — External plantar in 
sole of foot, 116 — Internal plantar, at origin, 117 — In sole of foot, 117. 

VI. Temporary ligation, 118 — Intermediate ligation, 118 — Arteriorrhaphy, 118 — Closure 
of wounds of larger arteries by special rubber plaster (Brewer's method), 124 — Aneurismor- 
rhaphy (Matas' method), 125 — Operation for the radical cure of anteriovenous aneurisms, with 
preservation of circulation in artery and vein (Matas-Bickham operation), 133 — Ligation for 
radical cure of aneurism, 139 — Other operations for radical cure of aneurism, 139 — Arterial 
forcipressure, 140 — Arteriostrepsis, 140 — YVyeth's treatment of vascular neoplasms, 14 r. 

3 



4 CONTENTS. 

CHAPTER IE 
OPERATIONS UPON VEINS. 

Phlebotomy, 142 — Phleborrhaphy, 142 — Lateral ligation of veins, 143 — Transverse liga- 
tion of veins, 144 -Temporary ligation of veins, 144 — Venous ligation en masse, 145 — Venous 
forcipressure, 145 — Phlebostrepsis, 145 — Acupressure of veins, 145 — Phlebectomy, 145 — - 
Intravenous infusion of normal salt solution, 140. 



CHAPTER III. 

OPERATIONS UPON LYMPHATIC GLANDS AND VESSELS. 

Surgical anatomy of thoracic duct, 148 — Suture of thoracic duct, 148 — Ligation of thoracic 
duct, 149 — Surgical anatomy of antero-lateral aspect of neck, 149 — Removal of lymphatic 
glands of neck, 151 — Surgical anatomy of axillary region, 154 — Removal of axillary lymphatic 
glands, 155 — Surgical anatomy of Scarpa's triangle, 155 — Removal of inguinal lymphatic 
glands, 156. 

CHAPTER IV. 
OPERATIONS UPON NERVES, PLEXUSES, AND GANGLIA. 

I. Neurotomy, 157 — Neurectomy, 158 — Neurectasy, 158 — Nerve-avulsion, 159— 
Neurorrhaphy, 160 — Neuroplasty, 163 — Nerve-grafting, 165 — Neurolysis, or an operation for 
relief of nerve-compression, 169 — Intraneural infiltration for regional anesthesia (operation 
of Matas and Crile), 169 — Paraneural infiltration for regional anesthesia (Matas' method), 
171 — Massive infiltration anesthesia with weak analgesic solutions (Matas' modification of 
Schleich's method), 172. 

II. Surgical Anatomy and Exposure of following Nerves and Ganglia of Head and Neck: — 
Gasserian ganglion and three divisions of fifth, by direct infra-arterial (Cushing's method), 175 — 
Same, by intracranial exposure (Hartley-Krause method), 177 — Same, by trephining through 
pterygomaxillary fossa (Rose's method), 181 — Supraorbital, at supraorbital foramen, 182 — 
Exposure of superior maxillary nerve at foramen rotundum by osteoplasic resection of malar 
and adjacent bones (Kocher's operation), 183 — Meckel's ganglion and superior maxillary, 
by antral route (Carnochan's operation), 185 — Same, by orbital route, 186 — Same, by pterygo- 
maxillary route (Braun-Loessen operation), 1S6 — Exposure of inferior maxillary nerve at foramen 
ovale by osteoplastic resection of malozygomatic arch (Kocher's operation), 188 — Inferior maxill- 
ary, at foramen ovale, 190; or superior maxillary, at foramen rotundum (Mixter's operation), 190 
— Inferior dental, in mouth (Paravicini's intrabuccal method), 191 — Through ascending ramus 
of inferior maxilla, 192 — At mental foramen, from within mouth, 193 — Lingual (gustatory) of 
inferior maxillary, in mouth, 194 — Facial, in front of mastoid process (Baum's operation), 195 — 
Spinal accessory, at anterior border of sternomastoid, 195 — Facio-accessory or facio-hypoglossal 
anastomosis for peripheral facial paralysis, 196 — Posterior divisions of first, second, and third 
cervical nerves (Keen's operation), 197 — Brachial plexus, in neck, 198 — Operation for brachial 
birth palsy, 199. 

III. Surgical Anatomy and Exposure of following Nerves of Upper Extremity and Thorax: 
— Median, in middle of arm, 201 — At bend of elbow, 202 — Ulnar, above middle of arm : 202 — 
Just above internal condyle of humerus, 203 — Musculospiral, below middle of arm, 203 — 
Intercostal, between angle and middle of rib, 204. 

IV. Surgical Anatomy and Exposure of following Nerves of Lower Extremity: — Anterior 
crural, below Poupart's ligament, 205 — Obturator, at thyroid foramen, 205 — Superior gluteal, 
upon buttock, 205 — Pudic, upon buttock, 205 — Great sciatic, at lower border of gluteus maximus, 
206 — Internal popliteal, at lower part of popliteal space, 206 — Posterior tibial, between origin 
and ankle, 207 — Behind internal malleolus, 207 — External popliteal (peroneal), behind tendon 
of biceps, 207 — Anterior tibial, near origin, 208. 

V. Surgical Anatomy of Cervical Sympathetic Ganglia and Cord, 208 — Total excision 
of cervical sympathetic ganglia and cord (Jonnesco's operation), 209. 

CHAPTER V. 
OPERATIONS UPON BONES. 

Osteotomy in general, 210— Linear osteotomy, by subcutaneous method, 211— Linear 
osteotomy, by open method, 213 — Cuneiform osteotomy, 214— The operative treatment of 
fractures in general, 214— Operations for recent or ununited fractures, by resection of ends 



CONTENTS. 5 

of bones, with retention of coaptated ends by immobilizing splints, 215 — Same, by suturing 
of ends of bones, with or without resection, 217 — Other operative methods of approximating 
and fixing ends of fractured bones, 221 — Operative treatment of simple fractures, 225 — Bone- 
grafting or bone-implantation, 227 — Operations for delayed union, non-union, and mal-union 
of fractures, 228 — Operative treatment of compound, comminuted, and complicated fractures, 
230 — Operative treatment of fractures involving joints and of fracture dislocations, 231 — 
Operative treatment of separated epiphyses, 232 — Operation for recent or ununited fracture 
of patella, by suturing soft parts (Stimson's method), 233 — Same, by wiring or suturing of bone 
and soft parts, 234 — Same, by an encircling suture of soft parts, 236 — Operation for recent 
or ununited fracture of olecranon, by wiring or suturing of bone and soft parts, 238 — Seques- 
trotomy, 239 — Osteoplasty, 240 — Excision, 240. 



CHAPTER VI. 
OPERATIONS UPON JOINTS. 

Exploratory puncture of joints, 241 — Arthrotomy, 241 — Arthroplasty, 241 — Arthrodesis, 
242 — Erasion, or arthrectomy, 242 — Operation for dislocated semilunar cartilages, 244 — 
Excision, 244. 

CHAPTER VII. 

OPERATIONS UPON MUSCLES. 

Myotomy, 245 — Myorrhaphy, 245 — Muscle-lengthening, 246. 

CHAPTER VIII. 
OPERATIONS UPON TENDONS AND TENDON-SHEATHS. 

Tenotomy, 249 — Tenorrhaphy, 251 — Tendon-lengthening, 254 — Tendon-shortening, 259 — 
Tendon-grafting, 261 — Operation for uniting tendon to periosteum (Lange's method), 263 — ■ 
Operation for uniting tendon to bone (Wolff's method), 264 — Transplantation of tendon with 
its osseous insertion, 265 — Repair of ruptured or divided tendon-sheaths, 265 — Excision of 
tendon-sheaths, 267. 

CHAPTER IX. 

OPERATIONS UPON LIGAMENTS. 

Syndesmotomy, 267 — Suturing of ligaments, 267 — Lengthening of ligaments, 267 — Shorten- 
ing of ligaments, 267. 

CHAPTER X. 

OPERATIONS UPON FASCIAE. 

Fasciotomy or aponeurotomy, 269 

CHAPTER XI. 
OPERATIONS UPON BURS^E. 

Puncture of bursas, 270 — Incision of bursa?, 270 — Excision of bursa?, 270. 

CHAPTER XII. 
AMPUTATIONS AND DISARTICULATIONS. 

I. General considerations, 271 — The general technic in amputating, 274 — Location of 
line of bone-section, or disarticulation, 274 — Location of limits of skin incisions, 275 — Incision 
of skin and fascia, 276 — Freeing of skin and fascia, 279 — Retraction of skin and fascia, 2S0 — 
Division of muscles in circular methods of amputation, 2S1 — Division of muscles in flap methods 
of amputation, 284 — Freeing and retracting of muscles, 2S8 — Making musculo-periostcal, or 



6 CONTENTS. 

periosteo-capsular, covering for end of bone, 289 — Retraction of soft parts preparatory to sawing 
bone, 292 — Sawing bone or bones, 292 — Removing splintered bone, 294 — Ligating arteries and 
veins, 295 — Treatment of nerves, tendons, and tags of muscle, fascia, and skin, 297 — Trimming 
of flaps, 297 — Re-amputation for improperly made flaps, 297 — Adjustment and suturing of 
musculo-periosteal, or periosteo-capsular, covering, 297 — Quilting of muscles, 298 — Drainage, 
300 — Suturing of stump, 300 — Dressing of wound, 301 — Removal of dressings, 301. 

II. The methods of amputation, 301 — The evolution of amputation methods, 301 — Sum- 
mary of amputation methods, 303 — Circular methods of amputation, 303 — Ordinary circular 
amputation (Amputation circulaire infundibuliforme), 303 — Cuff method of circular amputation 
(Circular amputation a la manchette), 305 — Modified circular amputation (mixed method), 
306 — Oval method, 307 — Racket method, 308 — Flap methods of amputation, 309 — Amputating 
by single flap of skin and muscle, 309 — By single flap of skin, 311 — By equal flaps of skin and 
muscle, 311— By equal flaps of skin, 311 — By unequal flaps of skin and muscle, 313 — By unequal 
flaps of skin, 314 — By unequal rectangular flaps of skin and muscle (Teale's method), 314 — 
Elliptical method, 315 — Osteoplastic amputations, 317 — Irregular methods of amputation, 
3*7 — Selection of amputation method, 317 — Primary, intermediate, and secondary amputa- 
tions, 319. 

III. The amputation stump, 319 — Qualities of a good stump, 319 — Characteristics of 
a bad stump, 320 — Conditions influencing vitality of stump, 320 — Contractility of tissues of 
stump, 321 — Position of stump cicatrices, 321 — Function of amputation-stumps, 321 — Site 
of amputation in connection with the resulting stump and its adaptability to an artificial limb, 
322. 

IV. Surgical Anatomy, Surface Form and Landmarks, General Surgical Considerations 
and Methods in Amputations and Disarticulations about the Fingers: — Amputation through 
last phalanx, by palmar flap, 327 — At second phalangeal joint, by palmar flap, 329 — Same, 
by short dorsal and long palmar flaps, 329 — Through second phalanx, by palmar flap, 330 — 
Same, by short dorsal and long palmar flaps, 330 — At first phalangeal joint, by palmar flap, 
331 — Same, by short dorsal and long palmar flaps, 331 — Through first phalanx, by palmar 
flap, 331 — Same, by short dorsal and long palmar flaps, 332 — At metacarpophalangeal joints 
of fingers in general, by oval method, 332 — Same of thumb, by oval method, 334 — Same of thumb, 
by oblique palmar flap (Farabeuf), 335 — Same of index, by externo-palmar flap (Farabeuf), 
335 — Same of little finger, by interno-palmar flap (Farabeuf), 336. 

V. Same, in Amputations and Disarticulations about the Hand: — Amputation of finger, 
in general, with part of its metacarpals, by racket method, 341 — Of thumb, with part of its 
metacarpal, by racket, 342 — Of little finger, with part of its metacarpal, by racket, 342 — Of two 
contiguous inside fingers, with part of their metacarpals, by racket, 342 — Of three innermost 
fingers, with parts of their metacarpals, by racket, 342 — Same, by equal dorsal and palmar 
flaps, 343 — Of all fingers (except thumb), with parts of their metacarpals, by anterior ellipse, 
343 — Of an inner finger, with its metacarpal, by racket, 344 — Of index, with its metacarpal, by 
racket, 344 — Of little finger, with its metacarpal, by racket, 344 — Of thumb, with its metacarpal, 
by racket, 345 — Of two continuous inside fingers, with their metacarpals, by racket, 346 — 
Of three inside fingers, with their metacarpals, by rackets, 346 — Of three inner fingers, with their 
metacarpals, by equal dorsal and palmar flaps, 346 — Of all fingers (except thumb), with their 
metacarpals, by anterior ellipse, 348 — Of fingers and thumb, at carpo-metacarpal articulation, 
by palmar flap, 348. 

VI. Same, in Disarticulations about the Wrist-joint: — Disarticulation at wrist-joint by 
anterior ellipse, 351 — By palmar flap, 352 — By external lateral, or radial, flap (Dubrueil's method), 
353- 

VII. Same, in Amputations about the Forearm: — Through lower third, by modified cir- 
cular, 356 — By circular (cuff variety), 357 — Through upper two-thirds, by equal anterior and 
posterior flaps, 358. 

VIII. Same, in Disarticulations about Elbow-joint: — Disarticulation of elbow-joint, by 
anterior ellipse (Farabeuf), 362 — By posterior ellipse, 363 — By long antero-internal and short 
postero-external flaps, 364. 

IX. Same, in Amputations about the Arm: — Amputation through lower third, by modified 
circular, 368 — Through upper two-thirds, by long anterior and short posterior flaps, 370 — 
Through surgical neck, by single external flap, 370. 

X. Same, in Disarticulations about the Shoulder-joint: — Disarticulation at shoulder-joint 
by anterior racket (Spence's operation), 378— By external racket (Larrey's operation), 381— 
By external or deltoid flap, 382. 

XI. Amputation of Upper Limb, together with Scapula and part of Clavicle, by antero- 
inferior (or pectoro-axillary) and postero-superior (or cervico-scapular) flaps (Berger's opera- 
tion), 383. 

XII. Surgical Anatomy, Surface Form and Landmarks, General Surgical Considerations, 
and Methods in Amputations and Disarticulations about the Toes: — Amputation through 
last phalanx, by plantar flap, 388— At second phalangeal joint, by plantar flap, 389— Through 



CONTENTS. 7 

second' phalanx, by plantar flap, 390 — At first phalangeal joint, by oval, 390 — Through first 
phalanx, by oval, 392 — Same, by circular, 392 — At metatarso-phalangeal joints of toes in general, 
by oval method, 392 — At' same of great toe, by interno-plantar flap (Farabeuf), 393 — At same 
of little toe, by externo-dorsal flap (Farabeuf), 394 — Disarticulation of two adjoining toes at 
metatarso-phalangeal joints, by oval method, 395 — Of toes en masse, at metatarso-phalangeal 
joint, by equal short dorsal and plantar flaps, 395. 

XIII. Same, in Amputations and Disarticulations about Foot: — Amputation of all toes 
through the metatarsus, by short dorsal and long plantar flaps (Metatarsal amputation), 402 — 
Disarticulation of toe, with its entire metatarsal, by racket method, 404 — Of great toe and its 
metatarsal, by racket, 404 — Of little toe and its metatarsal, by racket, 406 — Of two or three 
contiguous toes with their entire metatarsals, by oval or racket, 407 — Of all toes, at tarso- 
metatarsal joints, by short dorsal and long plantar flaps (Lisfranc's operation), 407 — Of all 
toes, at tarso-metatarsal joints, with sawing off of end of internal cuneiform, by short dorsal 
and long plantar flaps (Hey's operation), 408 — Of anterior part of foot at medio-tarsal joint, 
by short dorsal and long plantar flaps (Chopart's operation), 409 — Of foot at astragalo-scaphoid 
and astragalo-calcaneal joints, subastragaloid disarticulation, by large interno-plantar flap 
(Farabeuf), 410 — Of foot at astragalo-scaphoid and astragalo-calcaneal joints, subastragaloid 
disarticulation, by heel-flap, 412. 

XIY. Same, in Disarticulations about Ankle-joint: — Disarticulation of foot at ankle- 
joint, with removal of malleoli and articular surface of tibia, by heel-flap (Syme's operation), 
414 — Disarticulation of foot at ankle-joint, with removal of malleoli, articular surface of tibia, 
and anterior part of os calcis, by heel-flap (Pirogoff's operation), 415. 

XV. Same, in Amputation about the Leg: — Through supramalleolar region, by oblique 
elliptical incision (Guyon's supramalleolar operation), 419 — Through lower third, by large 
posterior and small anterior flaps (Farabeuf), 420 — Osteoplastic amputation, by long posterior 
and short anterior flaps, 422 — Through middle third, by long posterior and short anterior flaps 
(Hey's operation), 424 — Through upper third, by large external flap (Farabeuf), 425 — Same, 
by bilateral hooded flaps (Stephen Smith's method), 427 — Osteoplastic amputation, through 
upper third, by antero-internal flap (Bier's method), 429. 

XVI. Same, in Disarticulations about the Knee-joint: — Disarticulation at knee-joint 
by bilateral hooded flaps (Stephen Smith), 434 — By an oblique curved incision, 435. 

XVII. Same, in Amputations about the Thigh: — Through condyles of femur, transcondyloid 
amputation, by shorter anterior and longer posterior flaps (Lister's modification of Carden's 
transcondyloid operation), 440 — Just above condyles of femur, with splitting of patella (supra- 
condyloid osteoplastic amputation of Gritti-Stokes) by longer anterior and shorter posterior 
flaps, 441 — Femorotibial osteoplastic amputation of lower limb, by longer anterior and shorter 
posterior flaps (Ssabanajeff's operation), 443 — Through lower third of thigh by oblique circular 
method, 444 — Through thigh in general, by long anterior and short posterior flaps, 446 — Same, 
by equal anterior and posterior flaps, 448 — Through thigh just below trochanters, by external 
oval method, 449. 

XVIII. Same, in Excisions about the Hip-joint: — Disarticulation at hip-joint by Wyeth's 
method, 456 — By external racket, 458 — By anterior racket, 459 — Interilio-abdominal amputa- 
tion (Keen's method), 460. 



CHAPTER XIII. 
EXCISIONS AND OSTEOPLASTIC RESECTIONS OF BONES AND JOINTS. 

I. General Considerations, 463 — Excision by subperiosteal method, 463 — Excision by 
open method, 467 — Excision of coccyx, by posterior median incision, 468 — Surgical anatomy 
in excisions about superior maxilla, excision of superior maxilla, by median incision (Fergusson's 
operation), 471 — Osteoplastic resection of superior maxilla, by vertical and horizontal incisions, 
473 — Chondroplastic resection of nasal cartilages, to expose nose and anterior nasopharynx 
by nasal route, by transverse incision (Rouge's operation), 473 — Osteoplastic resection of superior 
maxilla, to expose nasopharynx by palatine route, by transverse and median incisions (Annan- 
dale's operation), 474 — Osteoplastic resection of superior maxilla, to expose nasopharynx by 
maxillary route, by two semilunar incisions (Langenbeck's operation), 474 — Surgical anatomy 
in excisions about inferior maxilla, excision of temporomaxillary articulation, by angular incision, 
476 — Excision of inferior maxilla, by single incision along inferior and posterior borders, 477 — 
Osteoplastic resection of lower jaw, to expose structures in pharynx and upon floor of mouth, 
479 — Excision of ribs, in general, 479 — Excision of entire rib and costal cartilage by parallel 
incision over center of rib, 480 — Excision of clavicle, in general, 480 — Total excision of clavicle 
by long axial incision, 481 — Total excision of scapula, by straight incisions along spine and 
vertebral border, forming superior and inferior flaps, 482. 



8 CONTENTS. 

II. Surgical Anatomy, Surface Form and Landmarks, General Surgical Considerations 
and Methods in Excisions about the Fingers: — Excision of terminal phalanges, by U-shaped 
incision, 484 — Of second phalangeal joints, by two lateral incisions, 484 — Of second phalangeal 
joint of index, by dorso external incision, 486 — Of second phalangeal joint of little finger, by 
dorso-internal incision, 486 — Of second phalanges of fingers in general, by dorso-lateral incision, 
486 — Of second phalanx, by dorso-external incision, for index-finger, 486 — Of second phalanx 
of little finger, by dorso-internal incision, 487 — Of first phalangeal joints, by same methods 
as for second phalangeal joints, 487 — Of first phalanges of fingers in general, 487. 

III. Same, in Excisions about Hand: — Excision of metacarpophalangeal joints of fingers, 
in general, by dorso lateral incision, 487 — Of metacarpals, in general, by dorsal incision, 488 — 
Of metacarpal of thumb, by dorso-external incision, 489 — Of metacarpal of little finger, by 
dorso-internal incision, 489. 

IV. Same, in Excisions about Wrist-joint: — Excision of wrist by radial and ulnar dorsal 
incisions (Oilier), 490 — Same, by single dorso-radial incision (Boeckel-Langenbeck), 491 — 
Excision of wrist-joint, by single dorso-ulnar incision (Kocher's method), 492. 

V. Same, in Excisions about Bones of Forearm: — Total excision of ulna, by long posterior 
incision, 493 — Same, of radius, by long externo-dorsal incision, 494. ■ 

VI. Same, in Excision about Elbow-joint: — Excision of elbow -joint, by posterior median 
incision (Langenbeck), 495 — Same, by posterior bayonet-shaped incision, with or without an 
additional short vertical ulnar incision (Oilier), 497 — Excision of elbow-joint, by vertically 
curved dorso-external incision (Kocher's method), 498 — Excision of superior radio-ulnar articu- 
lation, by posterior vertical incision, 500. 

VII. Same, in Excisions about Humerus: — Excision of humerus, by long external incision, 
501. 

VIII. Same, in Excisions about Shoulder-joint and vicinity: — Excision of shoulder-joint, 
by anterior oblique incision, 502 — Osteoplastic resection of shoulder-joint, by posterior curved 
incision (Kocher's method), 503. 

IX. Same, in Excisions about the Toes: — Excision of terminal phalanges, 423 — Of second 
phalangeal joints, 506 — Of second phalanges, 506 — Of first phalangeal joint, 506 — Of first 
phalanges, 507. 

X. Same, in Excisions about Foot: — Excision of metatarso-phalangeal joints, 507 — Of 
metatarsals, 507 — Of astragalus, by external curved incision, 507 — Same, by external angular 
and internal curved incisions, 508 — Of os calcis, by horizontal curved and vertical incisions, 510. 

XI. Same, in Excisions about Ankle-joint: — Excision of ankle-joint, by transversely curved 
external incision (Lauenstcin), 511 — Same, by external curved and internal angular incisions, 
512 — Osteoplastic resection of anterior tarsus and tarsometatarsus, by internal and external 
dorsolateral incisions, 513 — Osteoplastic resection of mid-tarsus, by external transverse curved 
incision, 514 — Osteoplastic resection of posterior tarsus, by external curved incision, 515 — 
Osteoplastic resection of foot, by transverse upper and lower and oblique lateral incisions (Wladi- 
miroff-Mikulicz operation), 516 — Total excision of tarsus, by externo-lateral curved incision 
(modification of Wladimiroff-Mikulicz operation), 518. 

XII. Same, in Excisions about Bones of Leg:— Total excision of tibia, by internal vertical 
incision, 519 — Total excision of fibula, by posterior vertical incision, 520 — Total excision of 
patella, by vertical incision, 520. 

XIII. Same, in Excisions about the Knee-joint: — Excision of knee-joint, by curved trans- 
verse anterior incision, 522 — Excision of knee-joint, by vertically curved external incision 
(Kocher's method), 523. 

XIV. Same, in Excisions about Femur: — Excision of parts of diaphysis, by external vertical 
incision, 526. 

XV. Same, in Excisions about Hip-joint: — Excision of hip-joint, by external straight incision 
(Langenbeck), 528— Same, by anterior straight incision (Barker), 529— Same, by posterior 
angular incision (Kocher), 530— Excision of the innominate bone (Kocher), 531. 



CONTENTS. 
PART II. 

THE OPERATIONS OF SPECIAL SURGERY. 



CHAPTER I. 
OPERATIONS UPON THE HEAD. 

I. Crano-cerebral Region: — Surgical anatomy of scalp, skull, and brain, 533 — Chief 
cranial landmarks, 537 — Cranio-cerebral topography, 538 — Localization of brain areas, 543 — 
Chipault's method of cranio-cerebral localization, 540 — Bell's cyrtometer in Chipault's method 
of cranio-cerebral localization, 550 — Reid's method of same, 551 — Kroenlein's method of same, 
553 — Chiene's method of determining Rolandic fissure, 554 — General surgical considerations 
in cranio-cerebral operations, 554 — Instruments, 557 — Craniotomy, in general, 557 — Trephining, 
or circular craniotomy, 55S — Osteoplastic resection of skull, 565 — Linear craniotomy, 580 — 
Partial craniectomy, 581 — Exploratory puncture of brain, 5S4 — Operation for intracranial 
hemorrhage, 585 — Ligation of middle meningeal artery and its anterior and posterior branches, 
586 — Ligation of longitudinal or lateral sinuses, 586 — Operation for thrombosis of lateral sinus, 
588 — Trephining for fracture of skull, 590 — Operation for bullet-wound of brain, 591 — Opera- 
tion for exposure of a motor center, 593 — Puncture and drainage of lateral ventricles, 594 — 
Incision of cerebellar subarachnoid space for drainage (Parkin), 595 — Operation for cerebral 
abscess, 595 — For cerebellar abscess, 596 — For cerebral tumor, 597 — For cerebellar tumor, 599 
— Operations upon mastoid antrum and cells, 599 — Operations upon Gasserian ganglion, 599. 

II. Bony (Air) Sinuses of Head and Face: — Operations upon mastoid antrum and cells, 
600 — Surgical anatomy, 600 — Surface form and landmarks, 602 — General surgical considera- 
tions, 603 — Operation for exposure of mastoid antrum and cells (Antrum operation of Schwartze), 
604 — Operation for exposing mastoid antrum and cells, together with interior of tympanun 
and meatus, and the exenteration of middle-ear cavities (the tympano-mastoid exenteration, 
or radical operation, of Schwartze-Stacke, or Schwartze-Zaufal), 606 — Operations upon frontal 
sinuses, 608 — Surgical anatomy, surface form and landmarks, and general surgical considera- 
tions, 608, 609 — Instruments, 610 — Exposure and drainage of frontal sinuses, 610 — Operations 
upon maxillary sinuses, 611 — Surgical anatomy, surface form and landmarks, and general surgical 
considerations, 611, 612 — Instruments, 613 — Opening of maxillary sinus through its facial 
aspect, above alveolar margin, 613 — Opening through socket of second molar tooth, 614. 

III. Eyeball and Orbit: — Operations upon the eyeball, 614 — Surgical anatomy of orbit, 
614 — Enucleation of eyeball, 615 — Evisceration of eyeball, 616 — Exenteration of orbit, 616 — 
Exposure of entra-orbital and retrobulbar structures (Kroenlein's operation), 617. 

IV. Ear and Eustachian Tube: — Surgical anatomy of membrana tympani, 61 8 — Intro- 
duction of ear speculum for examination of membrana tympani, 618 — Paracentesis tympani, 
619 — Introduction of Eustachian catheter, 619. 

Y. Xose and Nasal Cavities, 619. 

VI. Tongue: — Surgical anatomy, 619 — General surgical considerations, 620 — Instruments, 
621 — Excision of limited portion of tongue, 622 — Excision through mouth, without preliminary 
ligation of lingual arteries (Whitehead), 622 — Excision through mouth, after preliminary ligation 
of Unguals in neck, 624 — Excision of tongue by median incision through lower lip, chin, and 
neck, with osteoplastic division of inferior maxilla (Kocher), 624 — Excision of tongue, together 
with cervical and submaxillary glands, by an incision in neck, after preliminary tracheotomy 
and ligation of lingual and facial ateries (Kocher), 627. 

CHAPTER II. 
OPERATIONS UPON THE SPINE AND SPINAL CORD. 

Surgical anatomy, 629 — Surface form and landmarks, 632 — General surgical considerations, 
642 — Osteoplastic resection of spine, 648 — Laminectomy, 661 — Subarachnoid puncture for 
spinal anesthesia, 666 — Lumbar puncture for diagnosis and therapeusis, 669 — Spinal puncture 
for drainage of subarachnoid space, 670 — Operative treatment of fractures of spine, 670 — 
Operative treatment of dislocations of spine, 672 — Operative treatment of fracture-dislocations 
of spine, 673 — Operative treatment of incised and penetrating wounds of cord, 674 — Operative 
treatment of gunshot wounds of cord, 675 — Intraspinal partial neurectomy of posterior nerve- 



IO CONTENTS. 

roots, 679 — Spina bifida, 679 — Operative treatment of posterior vertebral tubercular osteitis 
of spine, 685 — Operative treatment of anterior vertebral osteitis, Pott's disease, 685. 

CHAPTER III. 
OPERATIONS UPON THE NECK. 

I. Larynx: — Surgical anatomy of neck, 695 — Surgical anatomy of larynx, 695 — Surface 
form and landmarks, 695 — Instruments, 696 — Laryngotomy, 697 — Thyrotomy, 698 — Com- 
plete laryngectomy, 699 — Partial laryngectomy, 700 — Intubation of larynx (O'Dwyer), 701 — 
Other operations, 702. 

II. Trachea: — Surgical anatomy, 702 — Surface form and landmarks, 703 — General sur- 
gical considerations, 703 — Instruments, 703 — High tracheotomy, 704 — Low tracheotomy, 
706 — Other operations, 706. 

III. Pharynx: — Surgical anatomy, 707 — Instruments, 707 — Median pharyngotomy, by 
median vertical incision through mouth, 708 — Lateral pharyngotomy, by curved lateral incision 
through neck (Kocher), 708 — Subhyoid pharyngotomy, by transverse curved incision through 
neck, 709 — Exposure of retro-pharyngeal space, by lateral cervical incision along posterior 
border of sternomastoid (Chiene), 710. 

IY. Esophagus: — Surgical anatomy, 711 — General surgical considerations, 712 — Instru- 
ments, 712 — External cervical esophagotomy, 712 — Cervical esophagostomy, 714 — Partial 
cervical esophagectomy, 714 — Introduction of esophageal bougie, 715 — Other operations, 715. 

V. Tonsils: — Surgical anatomy, 717 — General surgical considerations, 717 — Instruments, 
717 — Tonsillotomy, 717 — Partial tonsillectomy through mouth, 718 — Complete tonsillectomy 
through mouth, 718 — Complete tonsillectomy through neck (Cheever), 719. 

VI. Parotid Gland and Stenson's: — Surgical anatomy, 721 — Instruments, 722 — Excision, 
722. 

VII. Submaxillary Gland and Wharton's Duct: — Surgical anatomy, 724 — Instruments, 
724 — Excision, 725. 

VIII. Sublingual Gland and Duct of Bartholin: — Surgical anatomy, 726 — Instruments, 
725 — Excision, through floor of mouth, 726. 

IX. Thyroid Gland: — Surgical anatomy, 727 — Instruments, 727 — Partial thyroidectomy, 
by angular incision (Kocher), 727 — Complete thyroidectomy, by transverse curved incision 
(Kocher), 729. 

CHAPTER IV. 

OPERATIONS UPON THE THORAX. 

I. Thoracic Wall and Contents: — Surgical anatomy, 731 — Surface form and landmarks, 
733 — Instruments, 734 — Chrondroplastic resection of chest-wall, by subcostal incision and 
temporary division of seventh, eighth, ninth, and tenth costal cartilages, 734. 

II. Female Mammary Gland: — Surgical anatomy, 736 — Surface form and landmarks, 
736 — General surgical considerations, 736 — Incision of breast, 737 — Partial excision of breast 
by elliptical incision, 737 — Radical excision, by Meyer's method, 738 — Radical excision, by Hal- 
sted's method, 741 — Radical excision, by Warren's method, 744 — Ordinary excision, by elliptcal 
incision, 745 — Subcutaneous excision, by inferior curved incision, 746. 

III. Superior Mediastinum: — Surgical anatomy, 747 — Surface form and landmarks, 
747 — General surgical considerations, 747. 

IV. Anterior Mediastinum: — Surgical anatomy, 748 — Anterior mediastinal thoracotomy, 
by long median incision (Milton's anterior mediastinotomy), 748 — Anterior mediastinal thora- 
cotomy, by osteoplasic resection of part of sternum corresponding with third, fourth, and fifth 
costal cartilages, 750 — Other operations, 752. 

V. Middle Mediastinum: — Surgical anatomy, 752 — Operations upon middle medias- 
tinum, 752. 

VI. Posterior Mediastinum: — Surgical anatomy, 752 — Posterior mediastinal thoracotomy, 
by thoracoplastic flap (Bryant), 752. 

VII. Diaphragm: — Surgical anatomy, 755 — Transthoracic exposure of diaphragm, by 
partial excision of two or three ribs, 756. 

VIII. Pleura;: — Surgical anatomy, 759 — Surface form and landmarks, 760 — Paracentesis 
thoracis, 761 — Intercostal thoracotomy, 761 — Thoracotomy, by partial excision of one or 
more ribs, 763 — Partial pleurectomy (Estlander's thoracoplastic operation), 765 — Partial 
pleurectomy (Schede's thoracoplastic operation), 768 — Total pleurectomy (Fowler's thoraco- 
plastic operation), 770 — Discission of pleura in chronic empyema (Ransohoff's operation), 
771 — Other operations, 771. 



CONTENTS. II 

IX. Lungs: — Surgical anatomy, 772 — General surgical considerations, 773 — Pneumotomy, 
through a cutaneo-muscular thoracoplastic flap, 774 — Partial pneumectomy, through cutaneo- 
musculo-osseous thoracoplastic flap, 776. 

X. Pericardium: — Surgical anatomy, 7S0 — Surface form and landmarks, 780 — Pericardio- 
centesis, 7S1 — Pericardiotomy, through intercostal incision, 7S2 — Exposure of pericardium 
and heart, by excision of left fifth costal cartilage, 7S4 — Pericardiorrhaphy, 7S5. 

XL Heart; — Surgical anatomy, 785 — Paracentesis of right auricle, 787 — Paracentesis of 
right ventricle, 787 — Exposure of heart and pericardium, by a thoracoplastic flap (Rotter's 
operation), 788 — Cardiorrhaphy, 790. 

XII. Thoracic Trachea: — Surgical anatomy, 791 — Thoracic tracheotomy, 791. 

XIII. Bronchi: — Surgical anatomy, 791 — Bronchotomy, 791. 

XIV. Thoracic Esophagus, 792 — Surgical anatomy, 792 — Thoracic esophagotomy, by 
posterior mediastinal osteoplastic flap operation, 792. 



CHAPTER V. 
OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 

I. Abdomino- pelvic Wall: — Surgical anatomy, 793 — Surface form and landmarks, 797 — 
General surgical considerations, 799 — Instruments, 801 — Median abdominal section, 801 — 
Anterolateral abdominal section, by McBurney's intramuscular "gridiron" incision, S07 — 
Anterolateral abdominal section, by the Harrington-Weir prolongation of the anterolateral 
intra-muscular incision through rectal sheath, with temporary displacement of rectus, 810 — 
Anterior abdominal section through rectal sheath, with temporary- displacement of rectus, by 
the Battle-Jalaguier-Kammerer method, 811 — Median inferior abdominal section by Pfannen- 
stiel's superficial transverse curved, and deep vertical incisions, 815 — Inferior anterolateral 
abdominal section, by Meyer's "hockey stick" incision, 817 — Inferior anterolateral abdominal 
section, by Fowler's angular incision, 818 — Superior anterolateral abdominal section, by oblique- 
subcostal incision, 818 — Exposure of hypochondriac regions by chondroplastic resection of 
chest-wall, by subcostal incision and temporary division of seventh, eighth, ninth, and tenth 
costal cartilages, S19 — Lateral abdominal section by Vischer's lumbo-iliac incision, S19. 

II. Peritoneum: — Surgical anatomy, 820 — General surgical considerations, 822 — Opera- 
tions for separation, division, or ligation of peritoneal adhesions, 822 — Paracentesis 
abdominis, 824 — Operative treatment of diffuse septic peritonitis (Murphy's method), 825 — 
Same (Blake's method), 826 — Operative treatment of intra-abdominal abscess, 829. 

III. Omentum: — Surgical anatomy, 830 — General surgical considerations, 831 — Ligation 
of omentum, 831 — Omental grafting, 832. 

IV. Mesentery: — Surgical anatomy, 833 — General surgical considerations, 833 — Partial 
excision, 833 — Suturing, 833. 

V. Intestines: — Surgical anatomy of small intestines, 833 — Surface form and landmarks 
of small intestines, 836 — Surgical anatomy of large intestines, 836 — Surface form and landmarks 
of large intestines, 839 — General surgical considerations in operations upon the intestines, S40 — 
Instruments, 840 — Enterotomy, 841 — Enterorrhaphy, in general, 841 — By Lembert's interrupted 
suture, S43 — By Czerny-Lembert interrupted suture, 844 — By Halsted's interrupted quilt or 
mattress suture, 845 — By Lembert's continuous suture, 846 — By Cushing's right-angled con- 
tinuous suture, 846 — By combined overhand continuous suture of all coats, followed by inter- 
rupted Lembert suturing of outer coats, 848 — Enterorrhaphy for wounds of intestine, 848 — ■ 
Partial enterectomy, 850 — Entero-enterostomy (intestinal anastomosis, approximation, and 
implantation) in general, 854 — (A) Entero-enterostomy by methods of simple suturing, in 
general, 855 — By simple continuous overhand suture of all coats, followed by interrupted or 
continuous Lembert sutures of outer coats, by author's method, 856 — By perforating mattress 
sutures knotted in lumen (Connell's method), 864 — By Czerny-Lembert interrupted suture, 
867 — By Halsted's method of interrupted mattress or quilt sutures, 868 — By Maunsell's invagina- 
tion method, 870 — (B) Entero-enterostomy by means of absorbable mechanical devices left 
within the intestines, in general, 878 — By means of absorbable bobbins, 879 — By absorbable 
buttons, 880 — By Ullmann's modification of Maunsell's method, 881 — By Coffey's method, 
883 — (C) Entero-enterostomy by means of non-absorbable mechanical devices left within the 
intestinal canal, in general, 883 — By means of the Murphy button, 885 — Lateral intestinal 
anastomosis by the Jaboulay button, 892 — Entero-enterostomy by Harrington's segmented 
rings, 893 — (D) Entero-enterostomy by mechanical means temporarily used for approxima- 
ting the intestinal edges during suturing, in general, 895 — By means of Lee's intestinal holder, 
895 — Excision of ilio-caecum, 899 — Appendicectomy, by McBurney's intramuscular operation, 
900 — Appendicectomy through the rectal sheath, 911 — Appendicectomy, by the non-intramus- 
cular method, 911 — Appendicectomy, by Weir's operation, 912 — Enterostomy, in general, 
913 — Right inguinal enterostomy (or ileostomy) for establishment of temporary fecal fistula 



12 CONTENTS. 

of a permanent artificial anus, 914 — Colostomy, in general, 916 — Left inguinal colostomy, 
917 — Anterior intramuscular colostomy (Mixter's operation), 921 — Left lumbar colostomy, 
924 — Operation for closure of fecal fistula and artificial anus, 927 — Enteroplasty, 930 — Opera- 
tion for intussusception (Jessett- Barker method), 930 — Colopexy, by Bryant's method, 
932 — Rectopexy, by Verneuil's method, 933 — Internal rectotomy, 934 — External rectotomy, 
934 — Excision of rectum, in general, 935 — Excision by sacral route by partial excision of sacrum 
(Kraske's operation), 935 — Excision by sacral route, by the Rehn-Rydygier osteoplastic flap 
method, 940 — Excision of lower part of rectum by perineal route, 942 — Operation for cure of 
hemorrhoids by ligation and excision (Allingham's method), 944 — Operation for cure of hemor- 
rhoids by excision (Whitehead's method), 945 — Operation for cure of hemorrhoids by clamp 
and cautery, 946 — Operation for cure of fistula-in-ano by incision, 947. 

VI. Stomach: — Surgical anatomy, 950 — Surface form and landmarks, 951 — General surgi- 
cal considerations, 951 — Instruments, 952 — Introduction of stomach-tube, 952 — Gastrotomy, 
by' median incision, 952 — Gastrotomy by oblique subcostal incision, 954 — Gastrorrhaphy, 
955 — Gastrostomy, in general, 956 — Gastrostomy, by Ssabanajew-Franck's method, 957 — 
Same, by Witzel's method, 959 — Same, by Marwedel's method, 962 — Same, by Kader's method, 
964 — Gastro-enterostomy, in general, 967 — Anterior gastro-enterostomy, by simple suturing 
(Wolfler's method), 968 — Same, by the Murphy button, followed by single or multiple intestinal 
anastomosis by the Jaboulay-Braun method, 971 — Posterior gastro-enterostomy, by von Hacker's 
method, 974 — Same, by the Murphy button, 978 — Gastrogastrostomy by Wolfler's method, 
979 — Gastroplication, by Weir's modification of Bircher's method, 981 — Same, Moynihan's 
modification of Bircher's operation, 983 — Gastropexy, 983 — Gastrolysis, 983 — Gastroplasty, 
9S4 — Pyloroplasty, by Heineke-Mikulicz method, 984 — Divulsion of pyloric orifice of stomach, 
by Loreta's method, 986 — Dilatation of cardiac orifice of stomach, 987 — Gastro-duodenostomy 
(Finney's operation), 987 — Pylorectomy, in general, 991 — Pylorectomy, followed by independent 
gastrojejunostomy (Mayo's operation), 991 — Pylorectomy, followed by end-in-side posterior 
gastro-duodenostomy, by Kocher's method, 994 — Pylorectomy followed by end-to-end gastro- 
enterostomy, by Billroth's method, 997 — Partial gastrectomy, of median portion, 999 — Total 
gastrectomy, 1001 — Operation for gastric ulcer, 1002. 

VII. Liver: — Surgical anatomy, 1004 — Surface form and landmarks, 1006 — General 
surgical considerations, 1006 — Instruments, 100S — Exploratory puncture of liver, 1008 — 
Hepatotomy, in general, 1009 — Anterior subcostal transperitoneal hepatotomy, by anterior 
oblique incision parallel with costal arch, 1010 — Exposure of liver by anterior subcostal trans- 
peritoneal route, by anterior vertical incision through right linca semilunaris, 10 12 — Exposure 
of liver by lateral subcostal transperitoneal route, by lateral horizontally curved incision below 
right twelfth rib, 1013 — Exposure of liver by intercostal subpleural route, by intercostal incision 
below level of pleura, 10 13 — Exposure of liver by subpleural route, by partial excision of one or 
more ribs below level of the pleura, 1014 — Exposure of liver by subpleural route, by partial 
excision of one or more ribs opposite the pleura, 10 14 — Exposure of liver by transpleural route, 
by partial excision of one or more ribs opposite the pleura, 1016 — Exposure of liver by chon- 
droplastic resection of right costal arch, by anterior oblique subcostal incision, 1017 — Hepator- 
rhaphy, 1019 — Hepatopexy, 1019 — Partial hepatectomy, 1019 — Operation for cirrhosis of liver, 
epiplorrhaphy, or epiplopexy (Talma-Drummond operation), 1021. 

VIII. Gall-bladder: — Surgical anatomy, 102 1 — Surface form and landmarks, 1022 — 
General surgical considerations, 1022 — Instruments, 1022 — Cholecystotomy, by vertical sub- 
costal incision, 1022 — Cholecystostomy, by oblique or vertical subcostal incision, 1024 — Cho- 
lecystenterostomy, by Murphy button, 1026 — Cholecystenterostomy by simple suturing, 1028 — 
Cholecystolithotrity, 1028 — Cholecystectomy, 1029. 

IX. Gall-ducts: — Surgical anatomy, 1030 — Surface form and landmarks, 1031 — Instru- 
ments, 1031 — General surgical considerations, 1031 — Supraduodenal choledochotomy, 1031 — 
Retroduodenal choledochotomy (Haaslers operation), 1034 — Transduodenal choledochostcmy 
(Kocher's operation), 1034 — Cysticotomy, 1035 — Hepaticotomy, 1036. 

X. Spleen: — Surgical anatomy, 1036 — Surface form and landmarks, 1037 — General 
surgical considerations, 1037 — Instruments, 1038 — Exploratory puncture, 1038 — Splenotomy, 
by oblique subcostal incision, 1038 — Exposure of spleen by subpleural route, by partial excision 
of one or two ribs, 1039 — Splenorrhaphy, 1039 — Splenopexy, 1039 — Partial splenectomy, by 
subcostal incision parallel with ribs, 1040 — Total splenectomy, by vertical incision in left inea 
semilunaris, 1041. 

XI. Pancreas: — Surgical anatomy, 1043 — Surface form and landmarks, 1044 — General 
surgical considerations, 1044 — Instruments, 1046 — Pancreatotomy, by gastrocolic route, 1046 — 
Partial pancreatectomy, by gastrocolic route, 1047. 

XII. Kidneys: — Surgical anatomy, 104S — Surface form and landmarks, 105 1 — General 
surgical considerations, 1052 — Instruments, 1053 — Retroperitoneal exposure of kidney by 
oblique lumbar incision, 1053 — Retroperitoneal exposure of kidney, by Koenig's augular lumbo- 
abdominal incision, 1056 — Retroperitoneal exposure of kidney, by lumbar intramuscular method, 
1057 — Transperitoneal exposure of kidney, by vertical incision in linea semilunaris (Langenbuch's 



CONTEXTS. 13 

operation), 1057 — Transperitoneal exposure of kidney by median abdominal section, 1059 — 
Exposure of kidney by combined abdominolumbar operation, by anterior transperitoneal and 
posterior retroperitoneal incisions, 1059 — Exploratory puncture of kidney, 1060 — Nephrotomy, 
1061 — Pyelotomy, 1062 — Nephrolithotomy, 1062 — Nephrorrhaphy, 1063 — Nephropexy, by 
suturing split and everted proper capsule of kidney to lumbar wall, Edebohls's operation, 
1064 — Nephropexy, by suturing split proper capsule and parenchyma of kidney to lumbar wall, 
by oblique lumbar incision, Tuffier's operation, 1068 — Nephropexy, by simple suturing, 1069 — 
Total nephrectomy, by oblique lumbar incision, 1070 — Partial nephrectomy, by oblique lumbar 
incision, 1072 — Subcapsular nephrectomy, 1072 — Total nephrectomy by anterior transperitoneal 
method, 1072. 

XIII. Ureters: — Surgical anatomy, 1073 — Surface form and landmarks, 1074 — General 
surgical considerations, 1075 — Instruments, 1076 — Exposure of ureters, in general, 1076 — 
Extraperitoneal exposure of the kidney and the entire ureter, by oblique lumbo-iliac incision, 
1076 — Ureterotomy, 1078 — Ureterorrhaphy, 1079 — Ureteroplasty, 10S0 — Uretero-ureteral anas- 
tomosis (uretero-uret'-rostomy), 1080 — Implantation of ureters, in general, 1084 — Implantation 
of ureters into bladder (ureterocystostomy), 10S5 — Implantation of ureters into large intestine 
(ureterorectostomy) by Fowler's method, 1086 — Implantation of ureters upon skin, 1089 — ■ 
Ureterectomy, in general, 1089 — Partial ureterectomy, by oblique lumbar incision, 1090 — 
Total ureterectomy, together with removal of kidney, by anterior median abdominal section, 
1090. 

XIY. Bladder: — Surgical anatomy, 1091 — Surface form and landmarks, 1092 — General 
surgical considerations, 1093 — Instruments, 1094 — Introduction of sound or catheter, 1094 — 
Paracentesis vesica 1 , 1095 — Cystotomy, in general, 1096 — Suprapubic cystotomy, 1096 — Lateral 
perineal cystotomy, for removal of vesical calculus, 1099 — Median perineal cystotomy, for 
removal of vesical calculus, 1102 — Cystorrhaphy, 1103 — Lithotrity, 1104 — Litholapaxy, 1104 — 
Vesical drainage, 110S — Partial cystectomy, 1109 — Total cystectomy, by suprapubic median 
vertical and transverse incisions, 11 10. 

CHAPTER VI. 
OPERATIONS UPON THE MALE GENITAL ORGANS. 

I. Penis: — Surgical anatomy, 11 n — Instruments, n n — Circumcision, n 12 — Partial 
amputation of penis, by flap method, 11 14 — Total amputation, n 16. 

II. Urethra: — Surgical anatomy of male urethra, 111S — Surgical anatomy of female 
urethra, n 19 — Surface form and landmarks, n 19 — General surgical considerations, n 19 — 
Instruments, 11 20 — Introduction of sound or catheter, n 20 — Meatotomy, 11 20 — Urethrotomy, 
in general, 1120 — Internal urethrotomy, by dilating urethrotome, 1121 — External perineal 
urethrotomy, upon grooved staff (Syme's operation), 1123 — External perineal urethrotomy, 
upon filiform guide (Gouley's operation), n 24 — External perineal urethrotomy upon grooved 
staff passed down to stricture (Wheelhouse's operation), n 25 — Perineal section, or external 
perineal urethrotomy without a guide (Cock's operation), 1126 — Urethrorrhaphy, 1127 — 
Urethrostomy, n 27. 

III. Scrotum and Testes: — Surgical anatomy, 1128 — Paracentesis tunica vaginalis, 1129 — 
Partial excision of scrotum, n 29 — Operation for hydrocele, by incision of tunica vaginalis, 
Volkmann's operation, 1131 — Operation for hydrocele, by eversion and suturing of tunica 
vaginalis (Jaboulay's operat'on), 1132 — Operation for hydrocele, by incision, with partial 
excision of tunica vaginalis, von Bergmann's operation, 1133 — Orchidectomy, 1 134. 

IV. Spermatic Cord: — Surgical anatomy, 113^ — Instruments, 1136 — Partial vasectomy, 
1 136 — Operation for radical cure of varicocele, Bennett's modification of Howse's operation, 

II37- 

V. Vesiculae Seminales and Ejaculatory Ducts: — Surgical anatomy, 1138 — Instruments, 
1 139 — Total excision of vesiculae seminales and part of ejaculatory ducts, by suprapubic retro- 
cystic extraperitoneal route, Young's operation, 1139- 

VI. Prostate Gland: — Surgical anatomy, 1140 — Instruments, 1141 — Prostatotomv — 
Prostatectomy, in general, 1141 — Suprapubic prostatectomy, by median vertical incision, 
1 142 — Perineal prostatectomy, by transverse curved incision, 1143 — Prostatectomy by the 
combined median suprapubic and median perineal incisions, Alexander's operation, 1144 — 
Note, 1 146. 

CHAPTER VII. 

OPERATIONS UPON THE FEMALE GENITAL ORGANS. 

I. Uterus: — Surgical anatomy of uterus, broad ligaments, round ligaments, and vagina, 
1147— Surface form and landmarks, 1 1 50 —Instruments, 1150 — Partial abdominal hysterectomy, 
together with removal of ovaries and tubes (partial abdominal hysterosalpingo-oophorectomy), 



14 CONTENTS. 

1 151 — Total abdominal hysterectomy, together with removal of ovaries and tubes (total abdomi- 
nal hysterosalpingo-oophorectomy), 11 53 — Total vaginal hysterectomy, 1153. 

II. Ovaries: — Surgical anatomy of ovaries, Fallopian tubes, 1150 — Ovariectomy, or oopho- 
rectomy, with removal of Fallopian tube (salpingo-ovariectomy, or salpingo-oophorectomy), 
1 1 60— Note, 1 1 62 . 



CHAPTER VIII. 
OPERATIONS FOR HERNIJE. 

I. Inguinal Hernia, 1163 — Surgical anatomy, 1163 — General surgical considerations, 
1164 — Instruments, 1166 — Operation for radical cure of oblique inguinal hernia (Bassini's 
method), 1166 — Operation for radical cure of same (Halsted's method), 1171. 

II. Femoral Hernia, 1174 — Surgical anatomy, 1174 — General surgical considerations, 
1 1 76 — Operation for radical cure of femoral hernia (Bassini's method), 11 76. 

III. Umbilical Hernia, n 78 — Surgical anatomy, n 78 — Operation for radical cure of 
umbilical hernia by excision of sac and suturing of freshened edges of ring, n 79 — Operation 
for radical cure of umbilical hernia (Mayo's overlapping method), n 81. 



Index 1185 



A TEXT-BOOK 



OPERATIVE SURGERY 



BICKHAM 



PART I. 
THE OPERATIONS OF GENERAL SURGERY. 



CHAPTER I. 

OPERATIONS UPON THE ARTERIES. 
LIGATION OF ARTERIES. 

GENERAL CONSIDERATIONS. 

Description. — The ligation of an artery signifies the constriction of the 
artery by means of a ligature, for the purpose of controlling the circulation in 
that vessel. 

Varieties of Ligation. — A ligation may be "terminal," where the cut 
end of an artery is tied; — " in continuity," where tied in its unbroken course; 
— "single," where but one ligation is used; — "double," where two are applied 
(as in dividing a vessel between ligatures); — "immediate," where applied 
directly to the artery proper; — "intermediate," where the ligature passes 
around more or less connective or other tissue surrounding the artery (as 
in ligation for parenchymatous hemorrhage); — "permanent," where applied 
to remain; — or "temporary," where applied for arrest of circulation for a brief 
period. 

Indications for Ligation of Arteries. — Wounds; aneurisms; hemor- 
rhage, from main trunk near site of ligation, or from either main trunk or 
one of its branches at a distance from site of ligation; rupture of vessels; 
angiomata; to control hemorrhage in operations distal to site of ligation; 
to lessen nutrition of inoperable tumors; to cause atrophy of an organ by 
diminishing its blood-supply. 

Preparation. — (i) General; — -none is necessary for the smaller ligations. 
In the case of the ligation of the larger arteries, the constitutional state of the 
patient should be looked after as in other major operations. (2) Local; — 
the usual antiseptic preparation of the part — the patient coming to the table 
with the site of operation in an aseptic dressing. 

Position. — Patient upon table of proper height, and so placed as to 
bring the involved artery most conveniently and advantageously before the 
surgeon. Surgeon stands where he can best manipulate, which is generally 
on the side of the operation, and usually cuts downward on the right, and 
upward on the left. Assistant generally stands opposite the surgeon, and 
exposes the field of operation by retraction, or assists in the steps of the 
ligation. The position of patient, surgeon, and assistant will vary according 
to the artery operated upon, and will be given in the individual operations. 

Instruments. — Esmarch bandage and tourniquet; scalpels, heavy and 
2 17 



18 OPERATIONS UPON THE ARTERIES. 

light; scissors, straight and curved, sharp-pointed and blunt; forceps, dis- 
secting and toothed; hemostatic forceps; grooved director; tenacula; re- 
tractors, various sizes and shapes; aneurism-needles, large and small, straight 
and laterally curved; ligature-carrier; ligaturing and suturing material (v. i.); 
needles, straight and curved, surgeon's and Hagedorn; needle-holder; wound- 
hooks; drainage materials (for special emergencies); special small needles, fine 
silk, and needle-holder for repairing wounds of vessels; means of illuminating 
deep wounds. 

Ligature Materials. — Plain catgut; chromicized catgut; kangaroo 
tendon; ox aorta: silk, plain and floss. For the closure of skin-wounds, 
silkworm-gut or silk sutures. 

(i) For the ligation of smaller arteries — plain catgut. (2) For medium 
arteries — chromicized catgut. (3) For largest arteries — kangaroo tendon 
(flat); ox aorta (flat); chromicized catgut; soft floss-silk. 

Steps of the Operation of Ligation. — For the satisfactory carrying 
out of a ligation, a systematic course should be followed in all cases, the 
proper steps of which are given below, in order. 

(a) Control of Circulation Preliminary to Operation. — In ligating 
the arteries of the head, neck, and trunk, no attempt is usually made to 
control the circulation by any means of pressure. In the limbs, also, it is 
rarely absolutely necessary. But where its use is preferred, — and the satis- 
faction of operating in a dry field is unquestionable, — the limb is first elevated, 
the soft parts massaged toward the trunk, and the tourniquet of Esmarch 
(without the previous use of the Esmarch rubber bandage) is applied around 
the limb, as high up as indicated. The sacrifice of the guiding pulsation 
(necessitated by the use of any form of constrictor) is counterbalanced by 
the dryness of the field, especially in prolonged and difficult operations. 

(b) Line of Artery. — This is determined in advance of any operative 
step, and is based upon a knowledge of the anatomy of the part. A knowledge 
of the chief variations in the course of the arteries should also be possessed. 
Acquaintance with the line of the special artery is an absolute pre-requisite — 
a correct line, properly followed, leading directly and expeditiously to the goal 
of the operation; — an incorrect line, once taken, often plunging the operator 
into unnecessary difficulties from the start, frequently requiring loss of time, 
retracing of steps, unnecessary injury to structures, and the regaining of the 
right path finally after considerable and humiliating bungling. This line 
of the artery may be previously marked out upon the body with a sterilized 
dermographic pencil (or nitrate of silver stain) — but such marking is generally 
unnecessary. ( 1) The line of the artery is frequently modified by the position of 
the limb, and, in such cases, a constant position should be understood to apply 
in speaking of such arteries (for instance, the line of the brachial artery is one 
thing, if the arm be lying out supine at a right angle to the body, and another, 
if resting on its inner border parallel with the thorax. (Fig. 23.) On the 
other hand, no change in the position of the foot causes a change in the line 
of the dorsalis pedis (Fig. 54.) (2) The line of an artery often coincides so 
nearly with muscular or tendinous landmarks that these landmarks are often 
given instead of the line itself (for instance, one may speak of ligating the 
brachial artery by incising along a line extending from the junction of the 
anterior and middle thirds of the outer axillary boundary, to the middle of 
the bend of the elbow, the arm being at a right angle to the body and on its 
extensor surface; or one may also speak of ligating this artery by incising 
along the inner border of the coracobrachialis muscle above, and the biceps 
below, Fig. 23). It is well to know both the commonly accepted "line" 
and the natural muscular or other markings — the former is usually the more 



LIGATION OF ARTERIES. 19 

accurate guide to the vessel, especially in the early stage of the operation (for 
instance, in the above case, the brachial artery is often considerably overlapped 
by the biceps in a well-developed subject), though the latter are the natural 
boundaries, which generally have to be encountered and manipulated before 
finally reaching the artery. (3) In other cases the line bears no relation what- 
ever to external muscular or tendinous elevations or furrows, and, in such 
cases, the line alone has to be blindly followed, in the early part of the opera- 
tion, as a guide to the course of the artery (as in the case of the upper portion 
of the ulnar artery, Fig. 30). 

(c) Incision. — (I) Position and Direction of Incision: — In the great major- 
ity of cases the line of incision coincides with the line of the artery, from begin- 
ning to end of operation, superficially and in the deeper layers (as in ligation 
of the popliteal artery in the middle of the popliteal space), and should be so 
placed as to have its center over the site of ligation. In other cases the line 
of incision will follow a muscular marking, even if at a slight variance with 
the recognized "line of artery" (e. gr, in ligating the common carotid above 
the omohyoid, the incision is made parallel with the inner margin of the 
stern omastoid, which, in muscular and well-developed necks, is known to 
overlap and lie slightly to the inner side of the artery, Fig. 10, F). In other 
cases the incision follows neither line of artery nor muscular marking, but lies 
in a course parallel with both line of artery and muscular fibers, and is so placed 
as to reach the vessel most advantageously and with least damage to neighbor- 
ing structures (e. g., ligation of posterior tibial artery in middle of leg, Fig. 51, 
I). In other cases the incision may coincide with the line of artery but cross an 
overlying muscle at a right angle (e. g., ligation of lingual artery beneath the 
hyoglossus muscle, Fig. 10, L). In still other cases the incision may cross the 
course of the artery at a right angle (e. g., ligation of external iliac extraperi- 
toneally, by an incision parallel with Poupart's ligament, Fig. 39). (2) Super- 
ficial Incision : — Having chosen the line of incision as free from superficial vessels 
and nerves as circumstances permit, steady the area of incision by means of the 
left thumb and forefinger, which, by their separation, put the parts under 
slight tension and give room for the knife-cut between them. Grasp the scalpel 
in the "pen-position" for finer, more limited cuts, and in the "dinner-knife 
position" for heavier, longer cuts. Enter the point of the scalpel at a right 
angle to the skin surface — traverse the line of incision with the knife-handle at 
about 45 degrees — and withdraw the knife with the point of blade again at a 
right angle to the surface, thereby cutting to equal depth throughout. This 
incision should pass through skin and superficial fascia, and, while not unnec- 
essarily long, should be amply long enough to enable subsequent manipulations 
to be carried on without injury to the structures. The length of the incision 
should rather be determined by the depth of the artery and the nature of 
the parts to be encountered, than by any attempt to remember an arbitrary 
length of incision for each artery. The deep fascia is similarly divided in 
the original line — avoiding, where possible, superficial vessels, and, especially, 
nerves. (3) Deep Incision: — Having passed through all overlying fascia in 
the superficial incision, the muscle and tendinous landmarks now come to both 
sight and touch. Generally no further cutting is necessary — the rest of the 
approach "and exposure of the artery being accomplished by blunt dissection. 
In by far the majority of cases arteries are henceforth reached by following 
down between muscular planes, it being very rare that muscle-fibers are 
separated, and rarer still that muscles are cut transversely. At this stage of 
the operation the muscular or tendinous boundaries are recognized and followed 
to the known position of the artery, the intermuscular planes being separated 



20 OPERATIONS UPON THE ARTERIES. 

by the handle of the scalpel rather than by the blade, and this separation 
being carried out t<> correspond with the length of the superficial wound. 
The three best means of recognizing intermuscular planes, in the order of 
their reliability, are: — sense of touch of tip of left index-finger (which flexion 
of the limb may assist); — following down of intermuscular branches of the 
artery; — the white fascial, or yellow fatty, so-called ''line' ' in the intermuscular 
spaces. It is of great importance to recognize the proper intermuscular 
spa< e at the start, as, once in a wrong intermuscular interval, one may wander 
on indefinitely, completely off the track, missing the artery and doing much 
damage to the parts (and injury to one's own feelings). Good retraction 
should be freely used at this stage, and muscles and tendons should be drawn to 
their proper sides (flexing the limb often aiding considerably in this retraction). 
Important vessels, nerves, and other structures should be guarded during this 
separation of the parts, and, when in the way, should be displaced to the more 
convenient side of the operation-field — always remembering that nerves are 
the most important structures to be safeguarded, in the great majority of cases. 
If an Esmarch have not been used, the wound is kept comparatively dry by 
frequent sponging of the field with dry gauze-wipes. 

(d) Exposure of Artery. — Having gotten down into the region of muscles 
and tendons, these should be clearly identified, and the artery sought by its 
known relation to these structures. The muscles and tendons are the rallying- 
points in the depth of the wound. Three structures, outwardly more or less 
similar in appearance, and often in sensation, are to be distinguished: — (I) 
Arteries are recognized by their known course; their pulsation, when no 
proximal constriction is used (and by the hard, unyielding plaster or starch 
injection in the cadaver) ; their swelling proximally when compressed distaily 
(where no constrictor is used); their firm, round, resisting, elastic, cord-like 
feeling; their peculiar sensation when compressed between the fingers, present- 
ing a central depression and two lateral, elevated ridges; their thicker walls; 
their rubber-tube-like feeling when touched and tendency to glide from 
beneath the fingers; the force required to compress them; their regular outline; 
their pinkish or pinkish-yellow color. Of these means of recognition, pulsa- 
tion is the conclusive test, provided there can be eliminated all possibility 
of error caused by pulsation transmitted through contact (as a vein or a nerve 
made to rise and fall by an artery beating beneath or to one side of it). 

(2) Veins are recognized by not pulsating (where no Esmarch is used); by 
having thinner coats; by swelling toward the periphery when compressed cen- 
trally (no constrictor being used); by being softer and less resisting to touch; 
by the flat, ribbon-like feeling throughout their whole width when compressed 
between the fingers; by their purplish color; by their wavy, irregular contour; 
by their accompanying the arteries, in many regions, in pairs or companion 
veins; by their larger size than the corresponding arteries; by the ease with 
which they are compressed. It may be mentioned here, in connection with 
the companion veins, that two vena? comites are to be found accompanying 
all arteries below the axilla; all arteries below the knee; most of the small 
and medium-sized arteries of the trunk; and that the arteries of the head 
and neck are accompanied by single veins. These veins generally run on 
either side of the artery, communicating across the artery at frequent intervals, 
— generally lying in front of and behind the artery when the intermuscular 
plane enclosing the artery lies anteroposteriorly, — and usually lying to the 
right and left of the artery when the intermuscular plane runs transversely. 

(3) Nerves are distinguished by their known position; their white color; 
their round contour, unyielding consistency, and non-compressibility; their 



LIGATION OF ARTERIES. 21 

appearance of being made up of parallel bundles; their swelling neither 
proximally, like arteries, nor peripherally, like veins, when compressed (no 
constrictor being used). 

(e) Opening the Sheath. — Having identified this structure and brought 
it well within the field, its wall is to be opened and the contained artery ex- 
posed — for the purpose of clearing a path for the aneurism-needle (Fig. i). 
Only the main vessels have a distinct sheath of connective tissue, and the 
larger the artery, the more distinct the sheath. In some cases the accom- 
panying vein and nerve are included in a common sheath, together with 
the artery — the sheath being composed of more or less condensed connective 
tissue. The smaller arteries are surrounded by a less distinct layer of areolar 
tissue, generally not demonstrable as a sheath. The sheath should be opened 
at least 1.3 cm. (h inch) from any branch. With a pair of finely pointed 
forceps, pick up the sheath where it is desired to pass the ligature, and in 
such a way as to raise the sheath in a fold parallel with the long axis of the 




Fig. 1. — Ligation of an Artery. Opening the sheath. A, Retraction of adjacent muscles; 
B, Toothed forceps raising sheath of artery in a longitudinal fold ; C, Incising sheath in long axis of 
artery ; D, Artery visible through incised sheath. 



vessel (Fig. 1, B). Let the forceps pick up the sheath upon its anterior 
aspect, but slightly to one side of the median longitudinal line, thereby leav- 
ing space to incise the sheath exactly in the middle line. After grasping the 
sheath, shift the forceps gently up and down to see that the sheath, held in 
the bight of the forceps, glides over the contained vessel, proving, thereby, 
that no part of the artery itself is picked up. This longitudinal fold of the 
sheath, while held by the forceps and lifted up from the artery, is incised in 
the long axis of the artery, for a distance of about 6 to 8 mm. (j to § 
inch) (the shorter the distance of separation of the sheath the better, to pre- 
serve the vasa vasorum), the flat surface of the knife being turned to the 
artery (Fig. 1, C). As soon as the incision is made in the sheath, a gap 
appears between the wall of the artery and the wall of the sheath (Fig. 1 . D). 
The hold of the forceps upon the wall of the sheath should be retained, not 
being relaxed after once grasping the fold of sheath. In ligating smaller 



22 OPERATIONS UPON THE ARTERIES. 

arteries, which have no well-defined sheath, the vessel is simply freed of all 
visible connective tissue. (This axial division of the sheath of the artery is 
preferable to the transverse division so often advised.) 

(f) Clearing the Artery. — A path for the passing of the ligature between 
the outer wall of the artery and the inner wall of the sheath is now to be 
made, and the best instrument with which to make it is the dull, flat end of 
a curved aneurism-needle (Fig. 2). Having retained the original hold of 
the forceps upon the sheath (Fig. 2, B), insinuate the end of the needle between 
this wall of the sheath and the artery, and while drawing this lip of the sheath 
gently away from the artery, carefully work the point of the needle around 
one-half of the circumference of the artery, in the connective-tissue plane 
between artery and sheath, by a combination of forward movement, on the 
part of the tip of the needle, with a side to side movement, on the part of the 
lateral margins of the curved tip, over a distance of from 6 to 8 mm. (\ to | inch) 
(Fig. 2, C). Having thus cleared a path around half the vessel, and still 




Fig. 2. — Ligation of an Artery. Clearing the artery. A, A, Retraction of adjacent muscles; 
B, Forceps grasping nearer lip of sheath ; C, Aneurism-needle clearing artery in its passage between 
sheath and vessel ; D, Forceps grasping further lip of sheath ; F, Aneurism-needle emerging between 
artery and further lip of sheath. 



holding the tip of the needle in the path already cleared, the forceps for the 
first time relinquishes its hold on the lip of the sheath originally grasped, and 
grasps the opposite lip of the sheath and similarly draws this part of the sheath 
away from the artery (Fig. 2, D), at the same time also similarly working 
the point of the needle onward and from side to side, until it clears a way com- 
pletely around the artery and appears between the vessel and the further lip 
of the sheath (Fig. 2, E). Throughout this entire manoeuvre the handle of 
the needle is held approximately at a right angle to the vessel, and the tip of 
the needle hugs the wall of the artery, especially while working under its deepest 
part, particularly where a common sheath contains other structures, and 
thereby is prevented from penetrating the sheath and injuring the vessels, 
nerves, or viscera beyond. 

(g) Passing the Ligature. — Once a passage has been cleared between 



LIGATION OF ARTERIES. 



23 



artery and sheath, the aneurism-needle readily traverses it — so that as soon as 
the needle has appeared on the further side of the artery, it is withdrawn. 
The needle is now threaded and carefully passed between vessel and sheath, 
through the previously cleared way, following precisely the same course and 
carrying out the same steps— first opening the entrance to the passage by 
drawing the sheath away with forceps — then hugging the vessel in making 
the circuit — and finally emerging on the opposite side between the vessel and 
the further lip of the sheath, which the forceps have now grasped and drawn 
away (Fig. 3, F, B, C). An aneurism-needle may be passed with a fine silk 
ligature-loop as a carrier, and through this "carrier" the proper ligature may 
be threaded and drawn back. There is no fixed rule for the direction in which 




Fig. 3.— Ligation of an Artery. Passing the ligature and tying the knot. A, A, Retraction 
of neighboring parts; B, Aneurism-needle carrying ligature beneath artery; C, Tenaculum drawing 
one end of ligature under artery, while aneurism-needle is being withdrawn ; D, Tying the knot; 
F, Retracting lip of sheath. 

Fig. 4. — Knot Used in Ligating Medium and Large Arteries. E, Two turns of a fric- 
tion-knot followed by a reef-knot, constituting a surgeon's knot. 



the needle should be passed in each case; the rule should be that the 
needle is to be passed from the more important structures toward the least im- 
portant, or from the structures more difficult to avoid toward those more easily 
avoided. Therefore the needle may enter the sheath in the reverse order 
to that in which it has been freed from the artery, or vice versa, as seems 
safest and easiest. Having passed the needle completely around the vessel, 
until its threaded eye protrudes on the opposite side, grasp one of the 
threads of the looped ligature with forceps or tenaculum, and, while thus 
held, carefully withdraw the needle, following the curve of the artery 
(Fig. 3, B, C). Thus a single thread is left beneath the vessel — an end 
coming out between the artery and sheath on either side. Some surgeons pass 



24 



OPERATIONS UPON THE ARTERIES. 



the needle unthreaded, and thread the eye on the opposite side, then, holding 
one arm of the ligature with forceps, withdraw the needle — with the same 
result. There is no objection to this method in simple cases where the artery 
is accessible and the threading easily done with the needle in situ (as in the 
lower third of the radial), but it should not be attempted in a region where 
the exposure is difficult (as in the retroperitoneal ligation of the common 
iliac). Such an instrument as the Cleaveland needle (ligature-carrier) is 
preferred to the common aneurism-needle by some — the instrument, being 
passed under the artery empty, grasps the ligature on the opposite side, and 
draws back one end under the vessel. In arteries too small to have sheaths 
the ligature is simply carried under and around the artery, which has been 
freed of all connective tissue, the general method being the same as just 
described. 

(h) Tying the Knot. — The largest arteries are most safely and satis- 
factorily tied with the "stay-knot" of 
Ballance and Edmunds. The stay- 
knot of these surgeons is made by con- 
ducting two or more bundles of soft 
floss-silk — or two or more pieces of 
kangaroo-tendon, catgut, silk-worm 
gut, or plain silk around the artery, 
parallel with each other and side by 
side; — the first hitch of a reef-knot 
is then tied in each bundle, so that 
two or more knots lie side by side, 
the force to tie them having been 
sufficient to closely approximate the 
inner and middle coats of the artery 
and completely stop the flow, but 
•r^s^Ol \ "HA % without rupturing these coats (Fig. 

5, A, and Fig. 7). A friction knot 
is even safer than the first hitch of a 
reef-knot, as the preliminary step — 
especially in tying the larger vessels. 
After tying these at first lightly, they 
are both taken up together and gently 
tightened simultaneously. The two 
or more ends of the bundles are then 
taken up on the one side, and the two 
or more ends of the other bundles on the opposite side, — the several 
bundles on each side now being regarded as one.- — and these two bundles 
are tied in a single knot, after the manner of the second step of a reef-knot 
(Fig. 6, B). Thus a knot is formed the first part of which will not slip while 
the second is being tied (which is apt to be the case in large arteries, especially 
if they be pulsating at the time, thus allowing the establishment of a small 
stream of blood). By this method a broad compression and approximation 
of the arterial coats will be accomplished, which will add strength to the site 
of ligation against secondary hemorrhage. This simple approximation is 
sufficient to excite endothelial proliferation and union of the opposed surfaces. 
It is hard to draw such a ligature tight enough to rupture the inner coats. An 
artery with its two inner coats ruptured by ligation has only the strength of 
its outer coat to withstand the strain of the circulation until the secondary 
phenomena take place, which permanently strengthen the site — prior to which 




Figs. 5 and 6.— Floss-silk Stay-knot of 
Ballance and Edmunds. A, First stage; B, 
Second stage. 



LIGATION OF ARTERIES. 



25 



secondary hemorrhage may occur. Several parallel strands of smaller-sized 
chromic catgut, led under the artery by a carrier, are sometimes used, thus 
securing width for the ligature and the consequent distribution of pressure. 
All medium-sized arteries should be tied with a surgeon's knot (a friction-knot 
followed by the second step of a reef-knot) (Fig. 4, E). All small arteries 



^ 




Fig. 7. — The Stay-knot 
of Ballance and Edmunds. 

Showing the first step of tying 
three kangaroo-tendon liga- 
tures. 





Fig. 8. — Showing the Pleating 
or the Coats or a Ligated Artery 
in Cross-section. (Modified from 
Ballance and Edmunds.) 



Fig. o. — Illustrating the Manner 
of Suturing the Wound, the Edges of 
which are put upon the Stretch by 
YYurND-HOOKS at Either End. Interrupted 
sutures are shown at one end and continuous 
suturing at the other end. 



are safely tied with tne reef-knot alone. In making tension upon the ends 
of the ligature, special care should be taken not to lift the artery out of its 
sheath. To avoid this, the tips of the right and left forefingers should come 
together, end to end, directly upon the knot in the act of being tied, and the 
tightening should be done by putting the terminal and middle knuckles of 
the index-fingers in apposition, back to back, and using them as fulcra (Fig. 



2 6 OPERATIONS UPON THE ARTERIES. 

3, D). The thumbs may be similarly used instead of the forefingers. It is 
a disputed point as to how much tension should be used in tightening a ligature. 
It may be said that it is best to tighten the ligature upon all large vessels suffi- 
ciently to thoroughly approximate their inner wall in pleats, thereby com- 
pletely closing the lumen, without rupturing their two inner coats (Fig. 
8). The same holds true of all diseased vessels, independently of their size. 
All medium vessels may be similarly ligated. The smaller arteries generally 
have their ligatures tightened sufficiently to rupture their inner and middle 
coats. A tightening almost sufficient to sever all coats, especially when using 
silk, is distinctly to be avoided. Secondary hemorrhage seems less frequent, 
and the strength of the vessel greater, where the vessels are only constricted 
enough to closely approximate the two inner coats, without causing their 
rupture. All knots should be cut comparatively short. A round ligature 
tightly drawn will rupture the inner coats; a broad ligature will do so far less 
readily. 

(i) Closure of Wound. — Where a large, well-marked sheath has been 
opened in exposing the artery, although not absolutely necessary, it is well 
to unite the edges of the sheath by one or two fine catgut sutures. Where 
anv muscle tissue has been incised in order to reach the artery, it is usually 
best to repair the divided muscle tissue by catgut sutures passed through 
the lips of the muscle wound — which suture becomes buried in the final 
steps of the operation. Where deep intermuscular planes have been opened 
up, and dead spaces are apt to be left, it is advisable to put in a few buried 
catgut sutures through the muscle tissue, drawing together the muscles into 
their normal intermuscular cleavage line. Where no muscle has been wounded, 
— and in the final step of those cases where muscle has been incised and 
sutured, — complete closure of the wound is accomplished by a line of inter- 
rupted silkworm-gut or silk sutures, or by a continuous silk suture — the 
suturing, in either case, being materially aided by putting the wound on 
the stretch by a wound-hook in either end (Fig. 9). No form of drainage 
is used in clean cases. A simple gauze and cotton dressing, held in place 
by a bandage, completes the dressing. 

(j) After-treatment. — Very little after-treatment is indicated in the 
ligation of the smaller arteries. Where a large artery is ligated, a splint 
should be incorporated in the dressing where feasible, in order to control 
all movement of the part. In the case of the main artery of a limb, the . 
limb should be encased in cotton, and artificial warmth applied in addition, 
until the new circulation is established. The limb is elevated in bed to 
favor venous return. The skin sutures are removed on the seventh or eighth 
day. A rest in bed of from two to four weeks is required in the ligation 
of the larger arteries. 

Local Results of Ligation. — Obliteration of artery at site of ligation. 
Establishment of a new (collateral) circulation. 

Chief Dangers in Ligation of Arteries. — Secondary hemorrhage. 
Gangrene. 

Comment. — (1) Where it is difficult or impossible to separate one or 
more veins from the artery, the artery and vein, or veins, may be included 
in the one ligature. (2) Especial care should be taken to avoid the inclusion 
of the smallest nerve in the ligature. (3) When a large vein is wounded, 
the wound should be at once closed by lateral ligature (Fig. 99), or by sutur- 
ing (Fig. 98), preferably the former. If this be not feasible, the vein should 
be ligated. All medium and small veins should be ligated if wounded. If 
the ligation of the artery can be accomplished without the likelihood of 



LIGATION OF INNOMINATE ARTERY. 



27 



again wounding the vein, it should be completed at the original site. If 
there be danger of further complication, a new site should be chosen just 
above or below the one originally selected. (4) It is held by some that 
secondary hemorrhage is less likely if an artery be ligated in two places, 
from 2.5 to 5 cm. (1 to 2 inches) apart, and then divided between these two 
ligatures, allowing each end to retract — upon the principle that the arteries 
of the body are constantly under longitudinal tension, and, when ligated in 
continuity (especially where the inner coats are severed), there are present 
the conditions calculated to predispose to secondary hemorrhage. Practical 
experience seems to have borne out the claim of the double ligature with 
division, but the operation is not always feasible, especially in the deeper, 
larger vessels. (5) All ligature material should be thoroughly pliable before 
being used. 

SURGICAL ANATOMY OF INNOMINATE ARTERY. 

Description. — Largest branch of arch of aorta. From 3.8 to 5 cm. 
(lh to 2 inches) in length. Arises from beginning of arch of aorta, opposite 
fourth dorsal vertebra; runs upward, forward, and to right, to upper border 
of right sternoclavicular articulation, where it divides into right common 
carotid and right subclavian. 

Relations. — Anteriorly: manubrium; origin sternohyoid; origin sterno- 
thyroid; right sternoclavicular joint; remains of thymus gland; left innominate 
vein; right inferior thyroid vein; inferior cervical cardiac branches of right 
pneumogastric. Posteriorly: trachea; right pleura. To right: right in- 
nominate vein; right pneumogastric nerve; right pleura. To left : left common 
carotid; remains of thymus gland; left inferior thyroid vein; trachea. 

Branches. — Thyroidea ima (sometimes) ; thymic branch (sometimes) ; 
bronchial branch (sometimes). 

Line of Artery. — From center of manubrium, to center of right sterno- 
clavicular joint. 

Indications for Ligation. — Aneurism of right carotid, subclavian, and 
of innominate itself. 

Sites of Ligation. — From 1.3 to 2 cm. (h to f inch) below bifurcation 
(Fig. 10, A, B, C, D, E). 

Comparison of Methods of Exposure of the Innominate. — Choice 
would be given to. methods of non-division of muscles, with retraction — 
the oblique incision thus being preferable to the angular one — where these 
incisions promise sufficient room for manipulation. Where more room is 
necessary, especially from abnormal displacement of the parts (as from 
aneurism), the angular incision, or the methods of partial resection, give more 
space for the safe carrying-out of the necessary steps; and of these latter, 
the method of partial resection upon the right aspect of the manubrio-clavicular 
region is applicable to cases where a more limited sacrifice of bone will suffice; 
and Bardenheuer's operation — or the splitting of the manubrium — where the 
maximum space is required. The innominate has also been ligated through 
a trephine-opening made through the manubrium sterni, after turning back 
a flap of soft parts. 

LIGATION OF INNOMINATE ARTERY 

BY ANGULAR INCISION (MOTT'S OPERATION i. 

Position. — Patient supine, chest raised, head backward and to opposite 
side. Surgeon to outer side of shoulder. Assistant opposite surgeon. 
Landmarks. — Clavicle; sternomastoid muscle; sternoclavicular joint. 



28 



OPERATIONS UPON THE ARTERIES. 



Incision. — A-shaped (on right). Horizontal portion of incision is 
made along upper margin of inner third of clavicle, for a distance of about 
7.5 cm. (3 inches). Oblique portion (meeting horizontal at an acute angle) 
is made along anterior margin of sternomastoid, for about 7.5 cm. (3 inches) 
(Fig. 10, A). 




Fig. 10. — Incisions for Ligation of Chief Arteries of Head and Neck :— A, A, Innom- 
inate, by angular incision; B, B, Same, by oblique incision; C, C, Same, by partial bony resection, 
through an oblique incision; D, O, Same, by partial buns resection ( Bardenheuer's operation); E, 
Same, by splitting manubrium; F, Common carotid, above omohyoid; G, Same, below omohyoid; 
H, External carotid, below digastric ; I, Same, above digastric ; J, Thyroid, at origin ; K. Lingual, at 
origin; L, Lingual, beneath hyoglossus ; M, Facial, over inferior maxilla; N, Occipital, behind mas- 
toid process; O, Temporal, just above zygoma ; P, Trunk of middle meningeal, by trephine-opening 
exposed by curved oblique incision (lower of two trephine-openings); Q, Anterior branch of middle 
meningeal, by trephine-opening exposed by horseshoe incision (higher of two trephine-openings |; R, 
Posterior branch of middle meningeal, by trephine-opening exposed by horseshoe incision; S, Internal 
carotid, near origin ; T, Third part of subclavian ; U, Transversalis colli and suprascapular, at outer 
margin of sternomastoid ; V, Internal mammary, in second intercostal space ; W, First part of axil- 
lary, by curved transverse incision below clavicle. 



LIGATION OF INNOMINATE ARTERY. 2 g 

Operation. — -Having incised skin and superficial fascia, this triangular 
flap is dissected upward. Cut the sternal and clavicular attachments of 
the sternomastoid, as far as exposed. The sternohyoid and sternothvroid 
muscles are also cut, or are nicked and drawn well inward. Expose, ligate 
doubly, and cut the anterior jugular vein between its two ligatures, lying 
beneath the sternomastoid; and also the right inferior thyroid vein. Divide 
the deep cervical fascia along the original lines of incision, thus exposing 
the common carotid. Open its sheath and follow to its origin, avoiding 
the recurrent laryngeal nerve. Thus guided to the innominate, clear its 
trunk — with especial care on the outer side, of the pneumogastric nerve, 
right innominate vein, and pleura — and pass the needle from these structures. 




Fig. ii. — Ligation of the Innominate Artery by an Angular Incision; Also of the 
Right Common Carotid below the Omohyoid, and of the Vertebral Near its Origin': — 
A, A, Platysma; B, B, B, B, Sternomastoid; C, C, Sternohyoid; D, D, Sternothyroid; E, Innomin- 
ate artery bifurcating into subclavian and common carotid; F, Internal jugular vein; G, Pneumo- 
gastric nerve; H, Vertebral artery; I, Trachea; J, Thyroid gland; K, Right sternoclavicular 
articulation. 



Comment. — (I) As the chief source of failure is secondary hemorrhage, 
the common carotid and vertebral arteries are also tied — being the chief 
sources through which the recurrent flow occurs. (2) This free section of 
muscles leaves, by their retraction, a deep gap at the root of the neck for 
infection and slow filling-up. As much repairing of cut muscle tissue as 
possible, by suturing, should, therefore, be done in completing the operation. 
(3) Artificial illumination is desirable in this operation. 

Collateral Circulation. — First aortic intercostal, with superior inter- 
costal of subclavian. Upper aortic intercostals, with thoracic branches of 
axillary and intercostals of internal mammary. Phrenic, with musculo- 
phrenic of internal mammary. Deep epigastric, with superior epigastric 
of internal mammary. Free communication of vertebrals and interna] 
carotids of opposite side, inside of skull. Communication of branches of 
opposite external carotids in middle line of face and neck. (MacCormac). 



3° 



OPERATIONS UPON THE ARTERIES 



LIGATION OF INNOMINATE ARTERY 

BY OBLIQUE INCISION. 

Position — Landmarks. — As for Mott's operation (page 27). 

Incision. — Begin at junction of middle and lower thirds of anterior 
border of right sternomastoid muscle — pass down along the lower third of 
its anterior margin — thence sweep over upper edge of the episternal notch 
onto the manubrium sterni (Fig. 10, B, B). 

Operation. — Incise skin, superficial fascia, platysma, and deep fascia 
(Fig. 12). Tie anterior jugular vein between two ligatures — also ligate the 




N 



Fig. 12. — Ligation of Innominate by Oblique Incision; Also of Right Common 
Carotid below Omohyoid; Vertebral Near Origin; and Inferior Thyroid Near Origin: 
— A, Platysma; B, Sternomastoid retracted outward and downward; C, Right sternoclavicular 
articulation; E, Manubrium sterni; F, Omohyoid; G, Sternohyoid; H, Sternothyroid; I, Thyroid 
gland; J, Innominate artery dividing into common carotid and subclavian; L, Inferior thyroid; 
M, Vertebral; N, Right innominate vein, with subclavian and internal jugular; O, Pneumo- 
gastric; P, Recurrent laryngeal; R, Nerves from loop between communicans and descendens 
hypoglossi; S, Superficial cervical nerves. 

transverse branch between the two anterior jugulars, if in the way. Draw 
the sternomastoid outward — and, if necessary, its inner, sternal portion may 
be divided. Draw inward the sternohyoid and sternothyroid muscles — and, 
if necessary, their sternal attachments may be partly or entirely cut. Incise 
the deep cervical fascia over the carotid sheath. Open the sheath and follow 
the common carotid behind the sternoclavicular articulation to the subclavian 
and to the innominate, guarding the recurrent laryngeal nerve behind the 
common carotid sheath. Ligate the right inferior thyroid vein. Clear the 



LIGATION OF INNOMINATE ARTERY. 



3 1 



innominate, avoiding the left innominate vein in front — the right pleura 
behind — and the right pneumogastric nerve, right innominate vein, and right 
pleura to the right. 

Comment. — (i) As above mentioned, under Mott's operation, the 
common carotid and vertebral arteries should also be tied — which can be 
done through this incision (2) By this separation and retraction of muscles 
(or partial division) less damage is done to the parts and less of a cavity 
is left. 



LIGATION OF INNOMINATE ARTERY 

BY PARTIAL BONY RESECTION— THROUGH TRANSVERSE AND VERTICAL 
INCISIONS— (BARDENHEUER'S OPERATION |. 

Description. — The following parts are excised through a combined 
transverse and vertical incision: — the right and left sternoclavicular articula- 
tions, sternal ends of right and left first ribs, sternal end of right second rib, 
and upper 2.5 cm. (1 inch) of manubrium — thus exposing the innominate. 

Position. — As in Mott's operation (page 27). 

Landmarks. — Suprasternal notch and manubrium; sternal ends of 
clavicles; inferior margin of thyroid cartilage. 

Incisions. — (1) Transverse incision — along upper border of sternum and 
over the surfaces of the inner thirds of both clavicles. (2) Vertical incision 
— from lower border of larynx, down the median line, and well onto the 
manubrium sterni (Fig. 10, D, D). 

Operation. — Carry both incisions through skin, superficial and deep 
fasciae. In the transverse incision, divide sternomastoids, sternohyoids, 
and sternothyroids. Subperiosteally resect (with Gigli saw, rongeur, bone- 
cutting forceps, or chisel) the inner extremities of the left clavicle and left 
first rib — for about 1.3 cm. (^ inch) of their extent. Having made this 
exposure of the upper and outer portion of the manubrium upon its left 
aspect, free, through this approach, the posterior surface of the manubrium 
subperiosteally. The manubrium is then cut transversely through at a level 
about 2.5 cm. (1 inch) below its upper border — the division being accom- 
plished, preferably, by a Gigli saw conducted beneath the bone, between it 
and the periosteum. The sternal ends of the right clavicle and the right 
first and second ribs, after having been well cleared, are divided close to the 
outer margin of the sternum, in the same manner as the manubrium was 
divided. The mass of bone detached by the above cuts is now removed. 
The periosteum is then incised in the median line — the inferior thyroid 
veins ligated — the left innominate vein depressed — the right innominate vein 
retracted — the right pneumogastric nerve and pleura guarded on the outer 
side and behind — the innominate artery cleared — and the ligature passed 
from the pleura and pneumogastric. 



LIGATION OF INNOMINATE ARTERY 

BY SPLITTING OF MANUBRIUM STERNI. 

Description. — The manubrium is exposed by a transverse incision — 
divided transversely at its junction with the gladiolus — then split vertically 
at its center — followed by the separation of the two halves of the manubrium 



32 OPERATIONS UPON THE ARTERIES. 

and the exposure of the innominate. Upon completing the operation, the 
bony parts are returned to their normal positions — with or without suturing 
of the edges of the vertically divided manubrium into apposition. 

Position. — Patient supine; shoulders raised; neck prominent. Surgeon 
to right side. Assistant opposite. 

Landmarks. — Sternoclavicular articulations; lower border of manubrium 
(marked by line extending transversely across between the articulations of 
the second ribs). 

Incision. — Curved transverse incision — passing from inner third of 
anterior surface of one clavicle to the inner third of the anterior surface of 
the opposite clavicle, and passing down over the manubrium to the junction 
of its upper and middle thirds (Fig. 10, E). 

Operation. — Having incised skin, fascia, and anterior borders of the 
platysma down to the bone, clamp and tie all bleeding vessels. Free the 
manubrium subperiosteally over its anterior surface, downward to the junc- 
tion of the manubrium and gladiolus, and upward to its superior border. 
Follow the superior border backward and downward along its posterior 
aspect — also freeing this surface subperiosteally as far as the junction of manu- 
brium and gladiolus. Retract the overlying soft parts on the anterior aspect 
of the manubrium and divide the sternum along the manubrio-gladiolar 
junction — accomplishing the division with a Gigli saw, if one can be conducted 
across beneath the bone, or by bone-cutting forceps. Through the opening 
thus made by the transverse division, carry a Gigli saw from the center of 
the lower border of the divided manubrium to the center of the suprasternal 
notch — and divide the manubrium vertically in its center, cutting from the 
manubrio-gladiolar junction upward toward the free superior border — the 
Gigli saw traveling between the posterior surface of the manubrium in front, 
and its periosteum posteriorly. After the completion of the vertical section, 
retract the two halves of the manubrium laterally — incise the posterior perios- 
teum — ligate the inferior thyroid veins — depress the left innominate vein, 
retract the right innominate vein — guard the right pneumogastric and pleura 
externally and posteriorly — clear the innominate — and pass the ligature from 
the pleura and pneumogastric. 

Comment. — Where it is wished to suture together the vertical borders 
of the split manubrium, two or three holes should be drilled on each side 
as soon as the manubrium has been exposed anteriorly and posteriorly, and 
before its division — the soft parts below being protected by some thin, flat 
metallic instrument during the drilling. 



SURGICAL ANATOMY OF COMMON CAROTID ARTERIES. 

Description.— (a) Right Common Carotid : About 9.5 cm. (3I inches) 
in length. Arises from bifurcation of innominate, behind right sternoclavicular 
articulation — passes upward and outward and slightly backward to upper 
border of thyroid cartilage (opposite fourth cervical vertebra, according to 
Morris; — third cervical vertebra, according to Gray) — there dividing into ex- 
ternal and internal carotids. In its course it is contained within a common 
sheath of connective tissue, which also includes internal jugular vein and 
pneumogastric nerve, each separated by a fibrous septum — the vein lying to 
outer side and slightly overlapping artery, and the pneumogastric lying 
between and posterior to both. The omohyoid muscle crosses common 



SURGICAL ANATOMY OF COMMON CAROTID ARTERIES. 3$ 

carotid opposite lower border of cricoid cartilage, and divides the artery, 
surgically, into a lower part, deeply placed^and an upper part, superfici- 
ally placed, (b) Left Common Carotid: About n. 5 cm. (4^ inches) in 
length. Arises from middle of transverse portion of arch of aorta — ascends 
upward and outward behind, but at some distance from, manubrium sterni, 
overlapped by left lung and pleura, and in front of trachea, to left sterno- 
clavicular articulation — whence its course, relations, and terminations are 
same as for right common carotid. The crossing and relations of the omo- 
hyoid muscle are also similar. 

Relations. — (a) Left Common Carotid in Thorax : Anteriorly — 
manubrium sterni; origin sternohyoid; origin sternothyroid (above three 
structures being at some distance); remains of thymus; fatty areolar tissue 
of superior mediastinum; left innominate vein. Posteriorly (from below 
upward) — trachea; esophagus; thoracic duct; recurrent laryngeal nerve. 
External (to left) — left pleura and lung (slightly overlapping); left pneumo- 
gastric; left subclavian (both of latter being somewhat posterior). Internally 
(to right) — innominate artery; trachea; remains of thymus gland; left 
inferior thyroid vein, (b) Both Common Carotids in Neck: Anteriorly 
— skin; superficial fascia; platysma; deep fascia; sternomastoid; sternohyoid; 
sternothyroid; omohyoid; anterior jugular vein; thyroid body (often overlaps); 
middle thyroid vein; superior thyroid vein; lingual vein; facial vein; middle 
sternomastoid artery; descendens hypoglossi nerve (generally upon, some- 
times within, sheath); communicantes hypoglossi; lymphatic glands. Poste- 
riorly — pneumogastric nerve; sympathetic nerve; cervical cardiac branches 
of sympathetic and pneumogastric nerves; recurrent laryngeal nerve; inferior 
thyroid artery; longus colli; rectus capitis anticus major. Externally — 
internal jugular vein; pneumogastric nerve. (On right side a space is left 
at root of neck by divergence of vein, in which pneumogastric nerve and 
vertebral artery are found; on left side the internal jugular vein overlaps 
this space). Internally (from below upward) — trachea; esophagus; re- 
current laryngeal nerve; branches of inferior thyroid artery; lateral lobe of 
thyroid body; cricoid cartilage; thyroid cartilage; lower part of pharynx; 
carotid glands. 

Branches. — None, ordinarily. 

Line. — (With head turned moderately to opposite side and upward) — 
from sternoclavicular articulation to a point midway between angle of jaw 
and tip of mastoid process — that portion of this line between the sterno- 
clavicular articulation and the level of the upper border of the thyroid cartilage 
representing the common carotid. From the clavicle a little external to the 
sternoclavicular articulation would more accurately represent the line. The 
anterior margin of the sternomastoid muscle overlaps the carotid throughout. 
The omohyoid muscle crosses the carotid opposite and directly over Chas- 
saignac's "carotid tubercle" (costal process of sixth cervical vertebra) — 
which is about 6.3 cm. (2^ inches) above the clavicle. 

Indications for Ligation. — Wounds of itself and branches of external 
and internal carotid; distal and proximal aneurism; distal angiomata; as a 
temporary ligature; to limit growth of inoperable tumors; hemorrhage from 
areas supplied by distal branches. 

Sites of Ligation. — Above the omohyoid muscle — place of election. 
Below the omohyoid — depth of artery and nature of relations make the 
operation more difficult and more fatal (Fig. 10, F and G). 
3 



34 



OPERATIONS UPON THE ARTERIES. 




Fig. 13. — Ligation of Right Common Carotid above Omohyoid: — A, A Platysma ; B, Ster- 
nomastoid (retracted outward I ; C, Omohyoid 1 retracted downward I ; D, Sternothyroid; E, Common 
carotid (its sheath incised above omohyoid); F, Sternomastoid artery; G, Internal jugular vein; 
H, Superior thyroid vein; I, Inferior thyroid vein; J, Communicating vein between anterior and 
external jugular ; K, One of transversalis colli nerves ; L, Nerves from loop between descendens and 
communicans hypoglossi. 



LIGATION OF COMMON CAROTID ARTERY 

ABOVE THE OMOHYOID MUSCLE. 

Position.— Patient supine; shoulders elevated; neck prominent; chin 
upward and to opposite side. Surgeon on side of operation, or on the right 
for both sides. 

Landmarks. — Line of artery; anterior border of sternomastoid; cricoid 
cartilage. 

Incision. — About 7.5 cm. (3 inches) in length, with center at level of 
cricoid cartilage — the incision lying in the line of the artery (Fig. 10, F). 

Operation. — Incise skin, superficial fascia, and platysma. Superficial 
veins connecting anterior and external jugulars, and sometimes intercom- 
municating veins between facial and anterior jugular, as well as cutaneous 
nerves, are encountered (Fig. 13). Divide the deep fascia along the anterior 
border of the sternomastoid and open up the cellular tissue. The upper 
border of the omohyoid is here exposed, either by direct incision or by follow- 
ing up the anterior border of the sternomastoid. Having identified the 
intersection of sternomastoid and omohyoid, the omohyoid is retracted 
downward (or may be divided if in the way) — and the sternomastoid outward. 
Flexing the chin aids during these manipulations, by relaxing the parts. 
The common carotid is now located as it crosses the "carotid tubercle" (see 
Anatomy, "Line," page 33). Clear its sheath, avoiding or tying the 
sternomastoid artery and the superior and middle thyroid veins. Carefully 
incise the sheath, approaching from the inner side, to avoid the descendens 



LIGATION OF COMMON CAROTID ARTERY. 



35 



hypoglossi nerve (generally on the antero-external side of the sheath) and 
the internal jugular vein, and see that artery is freed from its sheath in its 
entire circumference. Pass the needle from the internal jugular and pneu- 
mogastric nerve. 

Collateral Circulation. — Inferior thyroid, with superior thyroid. Deep 
cervical, with occipital. Transversalis colli, with occipital. Branches of 
two vertebrals, with branches of two external carotids. Circle of Willis. 



LIGATION OF COMMON CAROTID ARTERY 

BELOW THE OMOHVOID MUSCLE. 

Position — Landmarks. — As in the ligation above the omohyoid. 

Incision. —About 7.5 cm. (3 inches) in length, in line of artery — from 
just below cricoid cartilage to just above sternoclavicular articulation 
(Fig. 10, G). 




Fig. 14. — Cross-section of the Neck at the Level of the Seventh Cervical Ver- 
tebra: — A, A, Scaleni muscles; B, B, Sternocleidomastoid muscles; C, C, Sternohyoid and 
sternothyroid muscles; D, D, Common carotid arteries and internal jugular veins; E, E, Vertebral 
arteries and veins; F, F, Inferior thyroid arteries and veins. (Modified from Braune.) 

Operation. — Incise skin, superficial fascia, and platysma. Here are 
encountered the superficial veins between the facial, anterior and external 
jugular veins, and the cutaneous cervical nerves. Divide the deep fascia 
along the anterior border of the sternomastoid. Expose the inner border 
of this muscle, flexing the head to relax the parts. The sternohyoid is then 
exposed, and sometimes the underlying sternothyroid. The omohyoid is, 



36 OPERATIONS UPON THE ARTERIES. 

ordinarily, not brought into the field of operation. These muscles, if en- 
countered, are retracted in their respective directions, or may be divided 
as far as necessary. Tie the inferior thyroid veins. The sheath is to be 
exposed as, and with the precautions, mentioned in the above operation. 
The recurrent laryngeal nerve and the inferior thyroid artery are to be espe- 
cially guarded in operating at this site. 

Comment. — The ligation of the common carotid is more difficult on 
the left side, owing to the nearness of the internal jugular vein (see Anatomy, 
"Relations," page 32), and the operation is less frequently done than on 
the right side. 



SURGICAL ANATOMY OF EXTERNAL CAROTID ARTERY. 

Description.— The smaller of the two divisions of the common carotid. 
About 6.3 cm. {t.\ inches) in length. Begins opposite upper border of thyroid 
cartilage; passes upward, forward, and then backward, under the stylohyoid 
and posterior belly of the digastric, to the interval between neck of condyle 
of inferior maxilla and the external auditory meatus, where it divides, in 
the substance of the parotid gland, into the internal maxillary and temporal 
arteries. 

Relations. — Anteriorly: skin; superficial fascia; platysma; deep fascia; 
anterior border of sternomastoid; hypoglossal nerve; lingual vein, facial vein; 
posterior belly of digastric; stylohyoid; temporomaxillary vein; superior 
cervical lymphatic glands; branches of facial nerve; parotid gland. Poste- 
riorly: internal carotid artery; styloglossus; stylopharyngeus; glossopharyn- 
geal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament; parotid 
gland; superior laryngeal nerve. Externally: internal carotid artery. In- 
ternally: hyoid bone; pharynx; ramus of inferior maxilla; stylomaxillary 
ligament; submaxillary gland; parotid gland. 

Branches (from below). — Ascending pharyngeal; superior thyroid; 
lingual; facial; occipital; posterior auricular; temporal; internal maxillary. 

Line. — Upper part of line of common carotid artery (page 33). 

Indications for Ligation. — Wounds and aneurism of trunk and branches; 
hemorrhage from areas of branches; palliative in malignant growths; pre- 
liminary to operations; aneurism by anastomosis in the regions of the 
trunks. 

Sites of Ligation. — Below the digastric (between the superior thyroid 
and lingual branches) — place of election — the operation is easier and more 
branches are thus controlled. Above the digastric — the operation is more 
difficult and more apt to involve branches of the facial nerve. Note: — The 
digastric muscle crosses the artery about 3.2 cm. (\\ inches) above its origin, 
opposite the upper border of the thyroid cartilage. The lingual arises oppo- 
site the great cornu of the hyoid bone. (Fig. 10, H and I.) 

Comment. — (1) The external carotid may be distinguished from the in- 
ternal carotid by the presence of its branches and by being to the inner side 
of the external carotid. (2) The ligation of the external carotid is now 
generally done where formerly the common carotid was ligated for 
conditions of the former vessel and its branches — the practicability and 
desirability of the operation having been demonstrated by the work of 
Wyeth. 



LIGATION OF EXTERNAL CAROTID ARTERY. 37 

LIGATION OF EXTERNAL CAROTID ARTERY 

BELOW THE DIGASTRIC MUSCLE. 

Position. — As for the common carotid (page 34). 

Landmarks. — Sternomastoid; thyroid cartilage; angle of jaw. 

Incision. — About 7.5 cm. (3 inches) — along the anterior border of the 
sternomastoid, or slightly in front of border — from level of middle of thyroid 
cartilage, to near angle of jaw (Fig. 10, H). 

Operation. — Incise skin, superficial fascia, and platysma (Fig. 15). Tie 
any veins which may lie in the line of incision. Divide the deep fascia and 
expose the anterior border of the sternomastoid and draw it outward. Find 




Fig. 15.— Ligation of Right External Carotid below Digastric ; and also of Internal 
Carotid, Superior Thyroid, Lingual, Facial and Occipital, near Origin:— A, Superficial 
fascia; B, B, Platysma ; C, Cervical fascia ; D, Sternomastoid (retracted outward); E, Posterior belly 
of digastric; F, Hyoglossus, with lingual artery disappearing beneath it; G, Thyrohyoid M. ; H, 
Middle constrictor M. ; I, Inferior constrictor M. ; J, Tip of great cornu of hyoid bone ; K External 
carotid A.; L, Internal carotid; M, Superior thyroid; X, Facial; O, Occipital; P. Internal jugular 
V. ; Q, Lingual and facial veins emptying into internal jugular; R. Superior thyroid V.; S, Hypo- 
glossal N. ; T, Descendens noni N. 

the posterior belly of the digastric at the upper angle of the wound. Next, 
locate the hypoglossal nerve crossing the external carotid below the origin 
of the occipital artery. Locate the tip of the great cornu of the hyoid bone, 
opposite which the lingual artery arises. Having fixed the location of these 
three structures, and avoiding the superior thyroid, facial, and lingual veins; 
expose the artery opposite the tip of the great cornu of the hyoid. Clear 
the sheath and pass the ligature between the superior thyroid and lingual 
branches — guarding the descendens hypoglossi nerve in front, and the supe- 
rior laryngeal nerve passing behind the artery — directing the needle from 
the internal carotid. 



38 OPERATIONS UPON THE ARTERIES. 

Comment. — (1) The operation is not an easy one, and it is often difficult 
to recognize the branches. (2) Jacobson advises simultaneous ligation of 
the superior thyroid, the lingual, and, if possible, the ascending pharyngeal 
branches — on account of secondary hemorrhage. (3) Through this same 
incision the superior thyroid, lingual, facial, occipital, and ascending pharyn- 
geal may be ligated. 

Collateral Circulation. — Same as for the ligation of the common carotid 
above the omohyoid (page 34). 



LIGATION OF EXTERNAL CAROTID ARTERY 

ABOVE DIGASTRIC MUSCLE AND BEHIND RAMI'S OF JAW. 

Position. — As for the common carotid. 

Landmarks. — Line of artery; ramus of inferior maxilla. 

Incision. — From tragus of ear, to below angle of inferior maxilla, and 
placed just behind the ramus of the jaw, in the line of the artery (Fig. 10, I). 

Operation. — Incise skin and superficial fascia. Avoid, or doubly ligate 
and incise, the tributaries of the external jugular and facial veins. Divide 
the deep fascia. Expose the anterior border of the sternomastoid and retract 
outward. Expose the posterior belly of the digastric and stylohyoid and 
draw downward — partially or entirely dividing them if necessary. Avoid 
the branches of the facial nerve. Expose the parotid gland and draw upward 
and forward — thus exposing the vessel. Clear the artery and open its sheath 
— and pass the ligature around the artery prior to its entrance into the sub- 
stance of the parotid gland. Repair, by suturing, whatever muscles may 
have been incised. 



SURGICAL ANATOMY OF LINGUAL BRANCH OF EXTERNAL CAROTID. 

Description. — The third in order, and an anterior branch of the external 
carotid. Arises opposite, or a little below, the great cornu of the hyoid bone, 
about 2 cm. (| inch) above the bifurcation of the common carotid, (a) First 
or Oblique Portion: — lies in superior carotid triangle, extending obliquely 
upward to the external border of the hyoglossus, — being covered by skin, 
superficial fascia, piatysma, deep fascia, and hypoglossal nerve, — and resting 
on the middle constrictor and laryngeal nerve, (b) Second or Horizontal 
Portion: — lies in the digastric triangle, running horizontally beneath the hyo- 
glossus muscle, along the superior border of the hyoid bone, — being covered 
by the hyoglossus muscle (which separates the artery from the hypoglossal 
nerve, posterior belly of the digastric, stylohyoid muscle, and lingual vein), 
— and resting upon the middle constrictor of the pharynx and geniohyo- 
glossus. (c) Third or Ascending Portion: — ascends between the hyoglossus 
and geniohyoglossus to the inferior surface of the tongue, (d) Fourth or 
Terminal Portion: — runs forward to tip of tongue, lying between the lingualis 
and geniohyoglossus, and covered only by mucous membrane. Two venae 
comites accompany the lingual artery beneath the hyoglossus. The ranine 
vein runs on the superficial surface of the hyoglossus, below the hypoglossal 
nerve. Several veins follow the dorsalis linguae artery. 

Sites of Ligature. — Its first or second portions are the parts usually 
tied — and of these, the second is preferable (Fig. 10, K and L). 



LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID. 



39 



LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID 

NEAR ITS ORIGIN. 

Position — Landmarks. — As for ligation of external carotid below the 
digastric (page 35). 

Incision. — In line of external carotid, with its center opposite the body 
of the hyoid bone (Fig. 10, K). 

Operation. — Same, practically, as for ligation of external carotid below 
the digastric, the main vessel being first exposed and the origin of the lingual 
then located. 

Comment. — The first part of the lingual may also be tied, though less 
readily, by a transverse incision extending from the level of the body of the 
hyoid bone to the anterior border of the sternomastoid, the artery being 
exposed and tied just before passing under the hyoglossus muscle. 

LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID 

BENEATH THE HVOGLOSSUS. 

Position. — Patient supine; shoulders raised; neck prominent; head to 
opposite side and chin upward. Surgeon on side of operation, cutting from 
before backward on the right, and vice versa. 




_ M 



E 

Fig. 16. — Ligation of Right Lingual Artery beneath Hyoglossus: — A, A, Platysma; 
B, Transverse cervical fascia over submaxillary gland; C, Deep transverse cervical fascia under 
submaxillary gland; D, Submaxillary gland; E, Hyoid bone; F, Anterior belly of digastric; 
G, Posterior belly of digastric; H, Stylohyoid; I, Mylohyoid; J, Hyoglossus; K, Omohyoid; 
L, Thyrohyoid; M, Lingual artery see'n through incision in hyoglossus; N, Submental A.; O, 
Tributary of temporomaxillary V.; P, Tributary of anterior jugular V.; Q, Ranine V. (below); 
R, Transverse cervical nerve;' S, Superior laryngeal nerve and vessels; T, Hypoglossal N. 



40 OPERATIONS UPON THE ARTERIES. 

Landmarks. — Lower border of inferior maxilla; facial artery crossing 
inferior maxilla; hyoid bone. 

Incision. — Curved incision — beginning just below and external to sym- 
physis menti — and ending just below and internal to crossing of facial artery 
over inferior maxilla — its center being just above the greater cornu of the 
hyoid bone (Fig. 10, L). 

Operation. — Incise skin, superficial fascia, platysma, and deep fascia. 
Avoid or ligate tributaries of facial, anterior jugular, or temporomaxillary 
veins. Incise the transverse cervical fascia over the submaxillary gland — 
exposing the gland and retracting it upward, out of its bed, over the margin 
of the lower jaw (Fig. 16). Incise transversely the deep cervical fascia 
exposed by lifting out the submaxillary gland — and identify the mylohyoid 
muscle in the anterior aspect of the wound. Expose the two bellies of the 
digastric and firmly retract them downward at their point of attachment to 
the hyoid bone — which steadies the parts and renders the hyoglossus more 
prominent. Clear the surface of the hyoglossus and identify the hypoglossal 
nerve crossing its anterior aspect. The ranine vein crosses the same surface 
just below and parallel with the nerve and at about the same level as the 
artery lies on the opposite side of the muscle. Retract both hypoglossal 
nerve and ranine vein upward. Divide the hyoglossus transversely for 
about 1.3 cm. (| inch) just above and parallel with the hyoid bone. This 
incision falls just over the artery, which generally bulges into the opening 
as soon as it is made, or through which it is easily reached. Having 
isolated the artery, trace it backward until the dorsalis linguae branch 
is reached, so that the ligature may be placed upon its proximal side. 
Having passed the ligature, replace the submaxillary gland and close the 
wound. 

Comment. — The fascia of the submaxillary gland may be sutured over 
it, and the incision in the hyoglossus may be repaired by suturing, if either 
be considered indicated. 



SURGICAL ANATOMY OF FACIAL BRANCH OF EXTERNAL CAROTID. 

Description. — The fourth in order, and an anterior branch of the ex- 
ternal carotid. The Cervical Portion passes upward and forward in the 
posterior part of submaxillary triangle, under the digastric, stylohyoid, 
submaxillary gland, and horizontal ramus of inferior maxilla. The Facial 
Portion curves over lower border of inferior maxilla at the anterior border 
of masseter muscle — and, running forward and upward, crosses the cheek 
to the angle of mouth — thence upward along side of nose to end at internal 
canthus of eye. 

Relations. — Cervical portion rests on (from below upward) stylo- 
glossus; mylohyoid; submaxillary gland (in or under it); — and is covered by 
(from below upward) posterior belly of digastric; stylohyoid; hypoglossal 
nerve (generally); submaxillary gland (beneath or in its substance); inferior 
maxilla; lymphatic glands; fascia; platysma; skin. Facial portion rests on 
(from below upward) inferior maxilla; buccinator; levator anguli oris; levator 
labii superioris (sometimes); infraorbital branches of fifth nerve; — and is 
covered by (from below upward) risorius; zygomatici major and minor; 
supramaxillary and buccal branches of facial nerve; levator labii superioris; 
levator labii superioris alaeque nasi; infraorbital branches of facial- The 
cervical portion of the facial vein is more direct than the artery, and separated 



LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID. 



41 



from it by submaxillary gland, posterior belly of digastric, stylohyoid muscle, 
and hypoglossal nerve. The facial portion of the facial vein is also more 
direct than the facial portion of the facial artery, and is separated from its 
arterv by the zygomatic] major and minor. 

Sites of Ligation. — Near origin (less frequently), — over lower jaw (the 
usual selection) (Fig. 10, M). 



LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID 

NEAR ORIGIN. 

Position — Landmarks — Incision — Operation. — Practically the same as 
for ligation of the external carotid below the digastric. 

LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID 

OVER INFERIOR MAXILLA. 

Position. — Patient supine; shoulders raised; head thrown back and to 
opposite side. Surgeon on side of operation, or on right for both sides. 

Landmarks. — Anterior margin of masseter muscle; horizontal portion 
of inferior maxilla. 




Fig. 17. — Ligation of Right Facial over Border of Inferior Maxilla: — A, Cervical 
fascia; B, Platysma ; C, Deep cervical fascia; D, Submaxillary gland; E, Mylohyoid muscle; F. 
Inferior maxilla ; G, Masseter M. ; H, Depressor anguli oris ; I, Facial A.; J, Facial V. ; K, Submen- 
tal A. ; L, Supramaxillai y N. 



Incision. — About 2.5 cm. (1 inch) in length — placed along and under 
cover of lower border of lower jaw, with its center over the course of the 
artery (at the anterior margin of the masseter muscle) (Fig. 10, M). 

Operation. — Incise skin, superficial fascia, platysma, and deep fascia, 
when the artery should come into view — with the facial vein just posterior 
to it. Avoid branches of the facial nerve (Fig. 17). 



42 OPERATIONS UPON THE ARTERIES. 



SURGICAL ANATOMY OF OCCIPITAL BRANCH OF EXTERNAL 

CAROTID. 

Description. — The fifth in order, and a posterior branch of the external 
carotid — passing upward and backward to the interval between mastoid 
process of temporal and transverse process of atlas — thence horizontally 
backward in the occipital groove — thence upward onto the scalp. 

Relations. — First Part (internal to sternomastoid) — covered by skin, 
fascia, posterior belly of digastric; parotid gland; temporomaxillary vein; 
hypoglossal nerve; — and rests on internal carotid artery; hypoglossal nerve; 
pneumogastric nerve; internal jugular vein, and spinal accessory nerve. 
Second Part (beneath sternomastoid) — covered by sternomastoid; splenius 
capitis; trachelomastoid; origin of digastric; — and rests on capitis lateralis, in 
occipital groove of mastoid process of temporal, and on the insertion of 
superior oblique muscle. Third Part (external to sternomastoid) — covered 
by skin, aponeurosis uniting occipital attachments of sternomastoid and 
trapezius — and resting upon the complexus. It perforates this aponeurosis 
just mentioned, or the posterior belly itself of the occipitofrontalis, together 
with the great occipital nerve — and follows, roughly, the line of the lambdoid 
suture, between the integument and the cranial aponeurosis. Two venae 
comites accompany the occipital artery. 

Sites of Ligation. — Near its origin — and behind the mastoid process 
of the temporal — according to site of lesion requiring ligature (Fig. 10, N). 



LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID 

NEAR ORIGIN. 

Position — Landmarks — Incision — Operation. — As for ligation of the 
external carotid below the digastric (page 35). 



LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID 

BEHIND MASTOID PROCESS. 

Position. — Patient supine; shoulders and head elevated; head turned 
well to opposite side (or patient resting slightly to one side). Surgeon stands 
behind, on side of operation. 

Landmarks. — Mastoid process; external occipital protuberance. 

Incision. — About 5 cm. (2 inches) in length — beginning from tip of 
mastoid process and extending toward the external occipital protuberance 
(Fig. 10, N). 

Operation. — Having incised skin and fascia, divide the posterior half 
of the sternomastoid and its strong aponeurosis — then the splenius capitis — 
then as many fibers of the trachelomastoid as are in the way (Fig. 18). Relax 
and retract the muscles by turning the head to the side of the operation. 
Expose the artery deep down between the mastoid process of the temporal 
and the transverse process of the atlas, resting upon the superior oblique 
and complexus muscles. Having separated from it the accompanying veins, 
and having guarded the veins from the mastoid foramen, the ligature is 
passed. The lesser occipital nerve runs on the posterior surface of the sterno- 



LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID. 43 




Fig. 18. — Ligation of Left Occipital Artery behind Mastoid Process: — \, Posterior 
cervical fascia; B, Trapezius muscle; C, Sternomastoid; D, Splenius capitis; E, Trachelomastoid; 
F, Occipital artery and vena comites, lying upon complexus muscle; G, Great occipital nerve; 
H, Lesser occipital nerve; I, Posterior external jugular vein. 

mastoid, near its posterior border, and the great occipital nerve pierces the 
trapezius muscle near its outer border. 



SURGICAL ANATOMY OF TEMPORAL BRANCH OF EXTERNAL 

CAROTID. 

Description. — The seventh in order and the smaller but more direct 
of the two terminal branches of the external carotid. Arises in substance 
of parotid gland, opposite neck of inferior maxilla — and runs upward, beneath 
parotid gland, between condyle and external auditory meatus — thence upward, 
crossing the posterior root of the zygoma — and continuing upward under the 
attrahens aurem muscle and temporal aponeurosis for 3.8 cm. to 5 cm. (1^ 
to 2 inches), where it divides into anterior and posterior branches. A plexus 
of sympathetic nerves surrounds the vessel — -it is crossed by the temporofacial 
division of the facial nerve — and is accompanied by the auriculotemporal 
nerve. 

Sites of Ligation. — The main trunk may be ligated just above root of 
zygoma. The anterior and posterior branches may be ligated at their bifurca- 
tion, about 3.8 to 5 cm. (1^ to 2 inches) above the zygoma . 



LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID 

JUST ABOVE ZYGOMA. 

Position. — Patient supine; shoulders raised; head to opposite side. 
Surgeon on side of operation, cutting from above downward on right, and 
vice versa (or on right for both operations, cutting from above downward). 

Landmarks. — Tragus of ear; condyle of jaw; zygoma. 



44 



OPERATIONS UPON THE ARTERIES. 



Incision. — Vertical, about 2.5 to 3.8 cm. (1 to i\ inches) in length, over 
line of artery, with center over zygoma, and extending downward in the 
interval between the tragus of the ear and the condyle of the lower jaw 
(Fig. 10, O). 

Operation. — Incise skin and dense subcutaneous tissue and parotid 
fascia — when the artery will be exposed lying quite superficial as it crosses 
the zygoma. Avoid the accompanying vein posteriorly — also avoid the 
branches of the temporofacial division of the facial nerve and the auriculo- 
temporal nerve (Fig. 19). 




Fig. 19. — Ligation ok Right Temporal Just above Zygoma :— A, Temporal artery, with its 
anterior and posterior bifurcations, and its transverse facial, middle temporal, and anterior auricular 
branches; B, Temporal vein, with branches corresponding to those of artery ; C, Temporal branches 
of auriculotemporal nerve ; D, Branch of temporofacial division of facial nerve ; E, Temporal fascia. 



SURGICAL ANATOMY OF MIDDLE MENINGEAL BRANCH OF INTERNAL 
MAXILLARY BRANCH OF EXTERNAL CAROTID. 

Description. — The largest branch of the first or Maxillary Portion of 
the internal maxillary. Arises between internal lateral ligament and neck 
of inferior maxilla — and, under cover of external pterygoid, passes upward 
between the two roots of the auriculotemporal nerve to the foramen spinosum, 
being crossed by the chorda tympani nerve. It enters the skull through 
this foramen and ascends in the groove on the great wing of the sphenoid, 
where it divides into anterior and posterior branches which ramify between 
the bone and the dura. The point of bifurcation is generally given by anato- 
mists as corresponding, on the exterior of the skull, with a point 3.8 cm. (1^ 
inches) behind the external angular process of the frontal bone, and 3.8 to 
4.5 cm. (1^ to if inches) above the zygoma. The Anterior Branch runs in 
a groove on the great ala of the sphenoid and the anterior inferior angle of 
the parietal. The Posterior Branch crosses the squamous portion of the 
temporal and then enters the groove on the posterior inferior angle of the 
parietal bone. In the young these measurements are less. 

Indications for Ligation. — Intracranial hemorrhage. 

Sites of Ligation. — The common trunk, or the anterior or posterior 
branch, as indicated (Fig. 10, P, Q, R). 

Note. — Because of the practical surgical bearing of the middle meningeal 
artery and its branches, and because of the wide variations from each other 



SURGICAL ANATOMY OF MIDDLE MENINGEAL ARTERY. 45 

in the descriptions of the intracranial portion of the middle meningeal artery 
and its branches in various anatomies, and because of the equally wide 
variations of the artery and its branches, as actually found in the skull, 
from the text-book descriptions, — the following summary is given of the out- 
come of special research upon the subject made upon fifty dried skulls and 
thirty cadavera (representing 160, upon the two sides) by S. C. Plummer. 
In the following data it is to be remembered that, owing to beveling, the 
lower part of the coronal suture is 5 mm. to 1 cm. (y 3 ^- to f inch) more pos- 
terior on the inner than outer side of skull, and that the squamoparietal 
suture is from 1 to 1.5 cm. (f to § inch) lower on the inner than the outer 
side. 

Covering of Artery. — Instead of lying between dura and bone (as 
generally understood) the artery is really covered by a thin process of dura 
on its outer surface; hence its adherence to the dura in separation of the 
latter from the bone. 

Trunk of Middle Meningeal Artery, — (1) Present in 95 per cent. In 
50 per cent., anterior and posterior branches entered separately, or the trunk 
divided at the foramen spinosum. (2) Point of Division into Anterior and 
Posterior Branches: — 2 mm. to 5.5 cm. (little more than y 1 ^ to 2^ inches) from 
foramen spinosum in a direct line — (less than 1 cm. or T 7 g- inch) in 16 cases — 
between 1 and 3 cm. (y 7 ^ and iy\ inches) in 60 cases — over 3 cm. (iy\ ; - inches) 
in 19 cases. Bifurcation was 58 times upon squamous part of temporal — 21 
upon sphenoid — 15 upon squamosphenoidal suture — once on sphenoparietal 
suture. (Steiner, another investigator, found a common trunk present in 
only 43 per cent. — and found that bifurcation occurred in 57 per cent, at the 
foramen spinosum.) (3) Length: — corresponds with point of bifurcation, 
when point of bifurcation is not more than 2 cm. (f inch) above the foramen 
spinosum, — and from 1 mm. to 1.2 cm. (-^ to ^ inch) greater when the point 
of bifurcation is more than 2 cm. (f inch) above the foramen spinosum (due 
to curve in artery). (In Steiner's cases the length was from 1 to 3.5 cm., or 
§ to if inches, in 43 cases — and from 3.5 to 5 cm., or if to 2 inches, in 8 cases.) 
(4) Direction: — almost invariably outward — and more frequently outward 
and forward than outward and backward. Generallv runs outward for 2 mm. 
to 1.7 cm. (little more than T X g- to J inch) and thence outward and forward — 
running in a gentle curve. (5) Location: — almost always runs from foramen 
spinosum onto the temporal (sometimes first runs onto the sphenoid, or 
squamosphenoidal suture) — generally running from 5 mm. to 1 cm. ( T 3 g- to § 
inch) posterior to the squamosphenoidal suture; thence a long trunk generally 
runs onto the squamosphenoidal suture — and then onto the great wing of the 
sphenoid. 

Anterior Branch of Middle Meningeal Artery. — (1) Relative Size: — 
Generally the main branch and larger than the posterior. (2) Direction 
and Location: — Beginning at point at which lowest bifurcation occurs (v. s.), 
the anterior branch, after bifurcating on the squamous, squamosphenoidal 
suture, sphenoid, or on the sphenoparietal suture, as the case may be, passes 
forward and upward across the anterior and lower part of the squamous; — 
thence almost invariably crosses the upper part of the great wing of the 
sphenoid; — thence passes backward across the sphenoparietal suture onto the 
parietal — and runs thence generally upward and backward about parallel 
with the coronal suture, and generally within 2 mm. to 3 cm. (little 
more than y 1 ^ to iy 3 ^ inches) of it. Practically, the most constant position 
of the anterior branch is where it crosses the sphenoparietal suture — the cross- 



46 OPERATIONS UPON THE ARTERIES. 

ing may be at any part of its 1.5 cm. (nearly § inch) length, but is usually 
on its anterior half. (3) As to Branches of Anterior Branch: — The anterior 
branch did not divide in 44 per cent. In the 56 per cent, in which it did 
divide, it divided 25 times on the right and 31 on the left. There were 2 
branches in 49 cases — 3 branches in 5 cases — 4 branches in 2 cases; — and these 
divisions occurred 51 times on the parietal, 3 times on the sphenoparietal 
suture, and 2 times on the sphenoid. Kroenlein considers that the anterior 
branch, in the average case, divides into two branches, one of which runs 
up in front and one behind the rolandic fissure. Where the anterior branch 
divides into branches, one branch generally runs parallel with and within 
2 cm. (f inch) of the coronal suture. (4) Bony Canal: — In from 38 per cent. 
(Steiner) to 60 per cent. (Plummer), the anterior branch was found to run 
through a bony canal upon the anterior inferior angle of the parietal bone — 
the canal sometimes beginning upon the sphenoid — being from 3 mm. to 
2.S cm. (| to i£ incr.es) Ions;. 

Posterior Branch of Middle Meningeal Artery. — (1) Much less con- 
stant in size and position than anterior branch. Generally smaller — often 
appearing as, and mistaken for, a branch of the anterior branch. Some- 
times appears to be a continuation of the trunk and larger than the anterior — 
and sometimes is larger without appearing to be main trunk. (2) Direction: — 
At first outward and backward, or upward and backward — rarely directly 
backward. Subsequently, in majority of cases, it passes horizontally backward 
— exceptionally, downward and backward. (3) Location: — (a) In Majority 
of Cases: — it runs approximately parallel with squamoparietal suture, gener- 
ally within 1 cm. (f inch), never more than 2 cm. (f inch) from it — gradually 
approaching it — crossing it (unless its terminal branches are given off on the 
temporal bone) generally within 2 cm. (f inch) of its posterior end, passing 
thence onto the parietal bone — its small branches running onto the occipital, 
(It may at first run parallel with the squamosphenoidal suture. It may 
cross the squamoparietal suture onto the parietal bone at any point.) (b) 
In Other Cases: — sometimes it runs outward and backward over the squamo- 
petrosal suture, or upon the squamous parallel with and generally within 
1 cm. of the squamopetrosal suture — passing back over the base of the petrous 
bone, crossing the squamoparietal suture near its posterior end — thence back 
onto the parietal bone, superiorly to and parallel with the mastoparietal 
suture. (4) Branches of Posterior Branch : — In majority of cases the posterior 
branch divides into two branches — on the temporal bone, most frequently 
— on the parietal bone, next most frequently — and on the squamoparietal 
suture, least frequently. 

Summary. — (1) That no parts of the middle meningeal artery or its 
anterior or posterior branches have fixed relations, except the main trunk 
at its exit from the foramen spinosum, and the anterior branch where it 
crosses the sphenoparietal suture to reach anterior inferior angle of parietal. 
(2) That the common trunk is generally present. (3) That the anterior branch 
may be given off from the orbital branch of the lachrymal branch of the 
ophthalmic. (4) That a tendency to symmetry exists upon the two sides 
of the skull, but is not constant. (5) That the anterior branch runs through 
a bony canal in the anterior inferior angle of the parietal bone in the majority 
of cases. 



LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY. 



47 



LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY IN THE 

CRANIUM 

THROUGH TREPHINE-OPENING EXPOSED BY CURVED OBLIQUE INCISION. 

Position. — Patient supine; head supported, shaved and turned to oppo- 
site side; surgeon on side of operation. 

Landmarks. — A point is selected as the center of the trephine-opening 
which will fall over the trunk of the artery proximal to its bifurcation, — and 
which is taken to be about 3.8 cm. (i4 inches) behind the external angular 
process of the frontal bone and 2.5 cm. (1 inch) above the zygoma. 

Incision. — Begins at external angular process of frontal bone — passes 
obliquely downward and backward to the posterior end of the zygoma — and 
from this point upward and backward above the auricle (Fig. 10, P). 




Fig. 20. — Ligation of Trunk of Right Middle Meningeal through Trephine- 
opening in Temporal Fossa by Curved Oblique Incision: — A, Temporal muscle (iis 
posterior border retracted upward and forward); B, Zygomatic arch, and temporal fossa 'ust 
above; C, Main trunk and anterior and posterior branches of midd'e meningeal, exposed through 
trephine-open ng 1 which is here shown somewhat too high); D, Deep temporal artery; E, Super- 
ficial temporal artery and vein; F, Auriculotemporal nerve (retracted backward); G, Branches 
of facial nerve (retracted downward and backward). 



Operation. — (1) Having incised skin and temporal fascia, ligate the 
superficial temporal artery and vein, guarding the auriculotemporal nerve 
and branches of the facial (Fig. 20). Then carry the incision along the 
posterior border of the temporal muscle through the periosteum to the bone. 
Detach the temporal muscle forward subperiosteal!}', baring parts of the 
squamous, parietal, and sphenoid bones — guarding the deep temporal arteries. 
Firmly retract the soft parts thus freed upward and forward. (2) Using a 
trephine about 3.8 cm. (ih inches) in diameter, place its center over a point 
about 3.8 cm. (i^ inches) behind the external angular process and 2.5 cm. 
(1 inch) above the zygoma. Having removed the disc of bone (which is 
here thin), expose the artery — and pass the needle carefully, to avoid wounding 
the brain. (3) In completing the operation, the disc of bone may be replaced, 



48 OPERATIONS UPON THE ARTERIES. 

or not, according to the individual ideas of the surgeon. Allow the perios- 
teum and soft parts to re-occupy their normal positions. Suture the margins 
of severed periosteum with buried catgut. Repair by gut-suturing any 
muscle tissue which may have been cut and close the skin incision. 

Comment. — (i) This incision of Kocher, together with the subsequent 
retraction of the soft parts, involves less injury to the parts than the turning 
downward or upward of a semilunar or horseshoe flap, which is the method 
of approach most frequently adopted. (2) According to the researches of 
Plummer (v. s.), the osteoplastic flap operation of Hartley-Krause furnishes 
the best method of exposing the main trunk of the middle meningeal artery 
and its branches. (3) If the above trephine-opening expose the artery 
inconveniently near its circumference, the opening may be enlarged in the 
direction of the artery with rongeur forceps. 



LIGATION OF ANTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY 

IN THE CRANIUM 

THROUGH TREPHINE-OPENING EXPOSED. BV A HORSESHOE INCISION. 

Position. — As for ligation of main trunk. 

Landmarks. — A point is selected as the center of the trephine-opening 
which will fall over the anterior branch just beyond its bifurcation — and is 
taken to be about 3.8 cm. (ih inches) behind the external angular process 
of the frontal bone, and from 3.8 to 4.5 cm. (1^ to if inches) above the zygoma. 

Incision. — A horseshoe incision with its center over the above point 
and its convexity upward is outlined — its anterior limb being just behind 
the external angular process, and the posterior limb corresponding with a 
line extending vertically upward from the auditory meatus (Fig. 10, Q). 

Operation. — The incision is carried, throughout, through skin, temporal 
fascia, temporal muscle, and periosteum to bone. These soft parts are 
raised subperiosteally and turned downward. A trephine of about 3.8 cm. 
(1^ inches) diameter is applied with its center over the above point. The 
steps of the operation are, henceforth, the same, practically, as those for 
the main trunk (page 47). 

Comment. — (1) See the surgical anatomy of the middle meningeal 
artery and its branches for variations in the course of the anterior branch. 
(2) According to Chipault's method of cranio-cerebral localization (page 546), 
the anterior branch of the middle meningeal crosses the second tenths of the 
three primary lines. In following which method, therefore, the trephine 
should have its center placed over a line which will cross these tenths at 
about their middle. (3) According to the researches of Plummer (page 45), 
who recommends Kroenlein's method of locating the anterior branch as the 
best of several, the following points are of practical value: — (A) That site 
should be chosen — (a) Which is high enough to avoid missing the anterior 
branch in case it originates from the orbital branch; — (b) which is high enough 
to be above the orbital branch when that branch is only a communicating 
branch; — (c) which is least apt to fall over the bony canal in the anterior inferior 
angle of the parietal, and over the bony ridge along the lower portion of the 
coronal suture: — (B) That a 2.5 cm. (1 inch) trephine-opening placed just 
behind any portion of the coronal suture will almost certainly strike the ante- 
rior branch, or a branch of the anterior branch. (4) According to Kroenlein's 
method, Reid's base line (page 551) is first drawn — then a higher line is drawn 
parallel with it and on a level with the supraorbital border. On the latter 
line a point is taken 3 or 4 cm. (iy F to i T 9 g- inches) behind the external angular 



SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. 49 

process. The center of the trephine will rest on the sphenoid in the majority 
of cases. (This corresponds, practically, with the data often given, of fixing 
upon a point from 3.2 to 3.8 cm. (i| to 1^ inches), according to the size of 
the head, behind the external angular process — and from 3.8 to 4.5 cm. (i£ 
to if inches) above the zygoma. 



LIGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY 

IN THE CRANIUM 

THROUGH TREPHINE-OPENING EXPOSED BY A HORSESHOE INCISION. 

Position. — As in ligating the main trunk. 

Landmarks. — A point is selected as the center of the trephine-opening 
which will fall over the posterior branch in the groove of the parietal bone — 
and is taken to be at the intersection of a line drawn horizontally backward 
on a level with the roof of the orbit, and one drawn vertically upward from 
directly behind the mastoid process — which point of intersection lies just 
below the parietal eminence (Jacobson). 

Incision. — A horseshoe incision with its center over the above point, 
its convexity upward, and its limbs being from 5 to 5.7 cm. (2 to i\ inches) 
apart (Fig. 10, R). 

Operation. — Performed in the same general manner as for ligation of 
the anterior branch (page 48). 

Comment. — (i) According to the researches of Plummer (page 45), 
who recommends Steiner's method as the best of several for locating the 
posterior branch, the following points are of practical value : — (A) The posterior 
branch is incapable of being located with as much certainty as the anterior 
branch: — (B) The lateral sinus is to be guarded in exposing the posterior 
branch. (2) According to Steiner's method, Reid's base-line is first drawn — 
then a second higher line is drawn parallel with it and on a level with the 
supraorbital border. A third line is drawn vertically upward along the 
anterior border of the mastoid (drawing the ear forward). The intersection 
of the third with the second line marks a convenient site for reaching the 
posterior branch. The trephine-pin rests on the squamoparietal suture. 
When the posterior branch itself is not encountered, its two branches usu- 
ally are. 



SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. 

Description. — The larger of the two branches of the common carotid. 
Arises opposite upper border of thyroid cartilage (on level with fourth cervical 
vertebra) — at first comparatively superficial, and lies slightly external to 
external carotid, then sinks more deeply in neck and passes posteriorly to 
that vessel — ascending neck in front of transverse processes of upper cervical 
vertebra.' to enter the carotid canal. The relations of its different portions 
are as follows: 

Relations. — (i) First or Cervical Portion :— Anteriorly (from below 
upward) — skin; superficial fascia; platysma; deep fascia; sternomastoid; 
posterior belly of digastric; stylohyoid; hypoglossal; occipital artery; posterior 
auricular artery; external carotid; styloglossus; stylopharyngeus; glosso- 
pharyngeal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament. 
Posteriorly — rectus capitis anticus major; transverse processes of three 



5° 



OPERATIONS UPON THE ARTERIES. 



upper cervical vertebra-; superior cervical ganglion; pneumogastric nerve; 
hypoglossal nerve; glossopharyngeal nerve; spinal accessory nerve; internal 
jugular vein. Externally— internal jugular vein; pneumogastric nerve. 
Internally— pharynx; superior constrictor; tonsil; ascending pharyngeal 
artery; ascending palatine artery; eustachian tube; levator palati. (2) 
Second or Petrous Portion :— Within carotid canal in petrous portion of 
temporal bone. (3) Third or Cavernous Portion :— Between layers of dura 
mater, forming cavernous sinus. (4) Fourth or Cerebral Portion : — Enters 
inner extremity of fissure of Sylvius and gives off its branches. 

Branches.'— From cervical portion— none. From petrous portion— 
tympanic; vidian. From cavernous portion — arteria receptaculi; pituitary; 
gasserian; anterior meningeal; ophthalmic. From cerebral portion— anterior 
cerebral; middle cerebral; posterior communicating; anterior choroid. 

Line.— Same, practically, as for the external carotid.,— or possibly a little 
to the outer side of that line at its lower part. 

Indications for Ligation. — Wounds; aneurism. 

Site of Ligation. — Near origin (Fig. 10, S). 



LIGATION OF INTERNAL CAROTID ARTERY 

NEAR ORIGIN. 

Position— Landmarks. — As for ligation of external carotid below the 
digastric (page 37). 

Incision.— Slightly posterior to the incision lor the external carotid 
artery— that is, along' the anterior border of the sternomastoid. instead of 
just in front of it — with the center of the incision about 1.3 cm. (h inch) above 
the upper border of the thyroid cartilage (Fig. 10, S). 

Operation. — The steps are, at first, the same as those for exposing the 
external carotid below the digastric. This artery (external carotid) is first 
sought (all the structures mentioned in that operation being encountered) 
and traced to its bifurcation, and thus the internal carotid is exposed — the 
external carotid being drawn inward and the digastric upward. In opening 
the sheath special care must be taken to guard the internal jugular vein, 
pneumogastric nerve, cervical sympathetic, ascending pharyngeal artery — ■ 
the needle being passed from the vagus and internal jugular vein (Fig. 15). 

Collateral Circulation. — Circle of Willis. 



SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. 

Description. — Subclavian artery on right side, about 7.5 cm. (3 inches) 
in length, arises from the innominate; and, on the left, about 10 cm. (4 inches) 
in length, arises from arch of aorta — arching, in both cases, across the root 
of neck, over the dome of the lung and pleura, to the lower border of the 
first rib, where it becomes the axillary artery. That portion of the subclavian 
internal to inner border of scalenus anticus being the first part — that portion 
behind this muscle being the second part — and that portion external to the 
outer border of scalenus anticus being the third part. The subclavian vein 
lies below and anterior to artery, the scalenus anticus intervening. The 
posterior border of the sternomastoid corresponds with the external border 
of the scalenus anticus. 

Relations.— (a) First Portion of Right Subclavian: — About 3 cm. 



SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. 5 1 

(i\ inches) in length' — arises from bifurcation of innominate, behind upper 
border of right sternoclavicular articulation — curves upward and outward 
(with convexity upward) at a variable distance above clavicle, over apex 
of right lung and pleura, to inner border of right scalenus anticus, hav- 
ing following relations: — Anteriorly — skin; superficial fascia; platysma; an- 
terior laver of deep fascia; clavicular origin of sternomastoid; sternohyoid; 
sternothvroid; deep cervical fascia; right innominate vein; internal 
jugular vein; vertebral vein; pneumogastric nerve; phrenic nerve; superior 
cardiac branches of sympathetic nerve: — Posteriorly — areolar tissue; longus 
colli; transverse process of seventh cervical and first dorsal vertebra; sym- 
pathetic nerve; inferior cardiac nerves; recurrent laryngeal nerve; apex of 
right lung and pleura; neck of first rib: — Inferiorly — pleura and lung; 
recurrent laryngeal nerve; subclavian vein, (b) First Portion of Left 
Subclavian: — Much longer than that of right — arises from distal end of 
transverse part of arch of aorta, opposite fourth dorsal vertebra, to left and 
slightly posterior to left common carotid — ascending, at first, almost vertically 
— then arching further upward and outward over apex of left lung and pleura 
to inner border of left scalenus anticus — having following relations: — Ante- 
riorly — left pleura and lung; sternothyroid; sternohyoid; sternomastoid; left 
innominate vein; internal jugular vein; vertebral vein; subclavian vein; phrenic 
nerve; pneumogastric nerve; left cervical cardiac nerves of sympathetic; 
left common carotid; thoracic duct: — Posteriorly — esophagus; thoracic duct; 
inferior cervical sympathetic ganglion; longus colli; vertebral column; left 
pleura and lung: — Externally — left pleura and lung: — Internally— trachea; 
recurrent laryngeal nerve; esophagus; thoracic duct, (c) Second Portions 
of Both Subclavian Arteries : — Highest part of the vessel — about 2 cm. 
(f inch) in length — lies behind scalenus anticus, which separates the artery 
from the subclavian vein — and has following relations: — Anteriorly — skin; 
superficial fascia; platysma; anterior layer of deep fascia; clavicular origin 
of sternomastoid; deep layer of deep fascia; phrenic nerve; subclavian vein; 
scalenus anticus: — Posteriorly — apex of lung and pleura; scalenus medius: — 
Superiorly— brachial plexus: — Inferiorly— lung and pleura, (d) Third 
Portions of Both Subclavians : — Lie in subclavian triangle (of sternomastoid, 
omohvoid, and clavicle). Extend from outer border of scalenus anticus 
downward and outward to lower border of first rib, and have following rela- 
tions: — Anteriorly — skin; superficial fascia; platysma; clavicular branches 
of descending portion of cervical plexus; anterior layer of deep fascia (from 
omohyoid to clavicle) ; posterior layer of deep fascia (from omohyoid to first 
rib); fatty areolar tissue between layers of deep cervical fascia; suprascapular 
artery; external jugular vein; suprascapular vein; transversalis colli vein; 
other tributary veins to external jugular; nerve to subclavius muscle; sterno- 
mastoid (sometimes); clavicle; subclavius muscle: — Posteriorly— scalenus 
medius; cord of brachial plexus formed by eighth cervical and first dorsal: 
— Superiorly— brachial plexus; posterior belly of omohyoid: — Inferiorly 
— first rib. 

Branches.— From First Portion : — vertebral, thyroid axis (inferior thyroid, 
transversalis colli, suprascapular), internal mammary. From Second Portion: 
— superior intercostal. From Third Portion: — no branches, ordinarily. 

Line.— A curve, with convexity upward, at base of posterior triangle- 
beginning at sternoclavicular articulation and ending at center of inferior 
border of clavicle— its mid-point being about 1.3 cm. (h inch) above the 
superior border of clavicle. 

Indications for Ligation.— Wounds; aneurism; preliminary to extensive 
operations about the shoulder and upper extremity. 



52 OPERATIONS UPON THE ARTERIES. 

Sites of Ligation.— But few successful cases of ligation of the first portion 
of the right subclavian are recorded and fewer of the left — the ligation being 
particularly hazardous, especially upon the latter side. Nor is ligature of the 
second portion to be recommended, owing to the depth and relations of the 
artery. The third portion is the part of the artery usually selected for ligation 
(Fig. 10, T). Ligation of the first portion of the subclavian differs slightly 
upon the two sides, owing to anatomical relations. 



LIGATION OF FIRST PORTION OF RIGHT SUBCLAVIAN 

BY ANGULAR INCISION. 

Position — Landmarks — Incision. — As for ligation of innominate by 
angular incision (page 27). 

Operation. — Having incised skin and superficial fascia, this triangular 
flap is dissected up, as in ligation of the innominate. The anterior jugular 
vein is doubly ligated and divided, and the external jugular similarly treated, 
if in the way. Divide the deep fascia. Expose and sever the sternal and 
clavicular heads of the sternomastoid. Divide the sternohyoid and sterno- 
thyroid either in whole or in part. Expose the common carotid, carefully 
retracting the internal jugular vein and pneumogastric nerve outward and 
displacing or doubly ligating any overlying veins. Identify the subclavian 
vein by following down the common carotid on its postero-external aspect 
to the bifurcation. Clear the subclavian artery, carefully guarding the 
recurrent laryngeal and phrenic nerves and vertebral artery. Displace the 
pleura downward and outward with tip of finger, and pass. the needle from 
below (from the pleura). The vertebral should also be secured at the same 
time and through the same incision — to accomplish which, the internal 
jugular and pneumogastric nerve are now retracted inward and the vertebral 
exposed by a few strokes of the knife as it lies between the longus colli and 
scalenus, guarding the phrenic and recurrent laryngeal nerves and the inferior 
thyroid artery. (Also see Fig. 12.) 

Comment. — Excision of the right sternoclavicular articulation may be 
done when necessary, as in the ligation of the innominate by partial bony 
resection. 

Collateral Circulation. — Superior thyroid, with inferior thyroid; one 
vertebral, with opposite vertebral. Internal mammary, with deep epigastric 
and aortic intercostals. Superior intercostal, with aortic intercostals. Pro- 
funda cervicis, with princeps cervicis. Scapular branches of thyroid axis, 
with branches of axillary. Thoracic branches of axillary, with aortic inter- 
costals. 



LIGATION OF FIRST PORTION OF LEFT SUBCLAVIAN 

BY ANGULAR INCISION. 

Position — Landmarks — Incision. — As for ligation of innominate by 
angular incision, except that the operation is placed upon the left side. 

Operation. — The steps of the operation are similar to those for ligation 
of the first portion of the right subclavian — up to the exposure of the common 
carotid and internal jugular. Here the common carotid and pneumogastric 
are retracted inward, the internal jugular is drawn outward and downward, 
and, with it, the left innominate vein. At this stage the head is bent forward 



LIGATION OF THIRD PORTION OF THE SUBCLAVIAN. 53 

to relax the parts. Special care is here given to identifying the thoracic 
duct before proceeding — the duct arching from the seventh cervical vertebra 
forward and downward over the subclavian artery in front of the scalenus 
anticus, and emptying into the left subclavian vein at the junction with it 
of the left internal jugular, being embedded in the loose areolar tissue of the 
part, making it often difficult to find, and sometimes dividing into several 
branches. Having safeguarded the important neighboring structures, follow 
down the common carotid with the finger until the subclavian is identified, 
on a plane posterior and external to that of the former vessel. The artery 
is then to be freed, carefully guarding the pleura; the sheath is opened and 
the needle passed from the pleura. 

Comment. — If more room be required than given by the above incision, 
or if it be required to ligate the vessel nearer the arch, an excision of the 
sternoclavicular articulation can be done. 

Collateral Circulation. — See Ligation of First Part of Right Subclavian. 



LIGATION OF SECOND PORTION OF SUBCLAVIAN ARTERY. 

Position — Landmarks — Incision. — As for ligation of third portion of 
subclavian. 

Operation. — The steps of this operation, up to the division of the deep 
cervical fascia and the recognition of the outer border of the scalenus anticus 
(which lies directly under the outer border of the sternomastoid), are identical 
with those for the exposure of the third part of the subclavian. The further 
steps consist in the inward retraction of the scalenus anticus (and overlying 
sternomastoid), with the division of as many of their fibers as necessary, when 
the artery will be exposed and may be ligated. Especial care is taken to 
guard the phrenic nerve, which crosses obliquely the lower anterior surface 
of the scalenus anticus, — as well as the transversalis colli and suprascapular 
arteries, which cross the scalenus anticus transversely, — and the external 
jugular vein, running parallel with the anterior scalene muscle. 

Comment. — This operation is often merely a proximal continuation of 
the operation for the exposure of the third part of the subclavian, when the 
application of a ligature to the third part is impracticable. 



LIGATION OF THIRD PORTION OF THE SUBCLAVIAN. 

Position. — Patient supine; shoulders raised; head thrown back and to 
opposite side; operated shoulder depressed by arm drawn downward and 
placed under the back (to open out the posterior cervical triangle). Surgeon 
in front of shoulder. 

Landmarks. — Posterior border of sternomastoid (which corresponds 
with the outer border of the scalenus anticus); anterior border of trapezius; 
middle of clavicle. 

Incision. — With the skin of the posterior cervical triangle drawn down 
over the clavicle by the left hand, an incision about 7.5 cm. (3 inches) is 
made transversely over the clavicle down to the bone, from the posterior 
border of the sternomastoid to the anterior border of the trapezius, and with 
its center about 2.5 cm. (1 inch) internal to the center of the superior border 
of the clavicle (Fig. 10, T). 

Operation. — (i) This incision will divide the skin, fascia, platysma, 



54 



OPERATIONS UPON THE ARTERIES. 



some supraclavicular nerves, and maybe a connecting vein between the 
cephalic and internal jugular— but will avoid the external jugular, which 
passes through the deep fascia above the clavicle. The incision will lie 
about 2.5 cm. (£ inch) above the clavicle when the tension upon the skin is 
relaxed (Fig. 21). (2) The margins of the sternomastoid and trapezius will 
be exposed, & and, if more room be needed, may be divided along the clavicle 
as far as necessary. (3) The deep cervical fascia is next incised, the external 
jugular vein being carefully exposed and retracted, or divided between double 
ligatures. Tributary vein's of the external jugular are to be similarly treated, 
especially the transv'ersalis colli and suprascapular. (4) Generally the trans- 
versaiis colli artery lies transversely above the incision, and the suprascap- 
ular transversely below it, under the clavicle and out of the way; but one or 




Fig. 21. — Ligation of Third Part of Right Subclavian: — A, Platysma; B, Trapezius; C 
Sternomastoid (posterior border incised); D, Scalenus amicus; E, Posterior belly of omohyoid (re- 
tracted upward); F, Clavicle ; G, Third part of subclavian ; H, Transversalis colli A.; I, Suprascapu- 
lar A.; J, Subclavian vein; K, Upper end of external jugular V. (divided and retracted), with 
transversalis colli V. and communicating branch to anterior jugular ; L, Lower end of external jugu- 
lar (divided and retracted), with suprascapular branch ; M, Brachial plexus; N, N, N, Supraclavicu- 
lar nerves ; O, Deep cervical fascia. 



both may present in the field, and are to be carefully preserved for collateral 
circulation. Retract the posterior belly of the omohyoid upward if in the 
way. Identify the outer margin of the scalenus (just under the outer margin 
of the sternomastoid) as a guide to the artery, and follow its outer border 
downward until the finger reaches the tubercle on the upper border of the 
first rib, which lies between the subclavian vein in front, and the subclavian 
artery behind — when the artery will be recognized and may be traced upward. 
(5) Expose the lowest cord of the brachial plexus — for the purpose of hence- 
forth avoiding it (as it has been mistaken and ligated for the artery). The 
subclavian vein will lie anteriorly and inferiorly to the artery. (6) Open 
the sheath — clear the artery — and pass the needle from the brachial plexus, 
guarding the subclavian vein and the pleura. 



LIGATION OF VERTEBRAL BRANCH OF SUBCLAVIAN. 55 

Collateral Circulation. — (When the second or third part is tied) : — Supra- 
scapular and posterior scapular above, with acromiothoracic, infrascapular, 
subscapular, and dorsalis scapuke below; internal mammary, superior inter- 
costals, aortic intercostals above, with long thoracic and scapular arteries 
below; plexiform vessels from branches of subclavian above, with branches 
of axillary below. 



SURGICAL ANATOMY OF VERTEBRAL ARTERY. 

Description. — Largest and generally first branch of subclavian. Arises 
from upper and posterior portion of first part of subclavian, near inner border 
of scalenus anticus — ascends upward, backward, and outward, in interval 
between scalenus anticus and longus colli, to foramen in transverse process 
of sixth cervical vertebra — passes through foramina in all vertebrae above 
this — emerging from foramen in transverse process of atlas, it runs in groove 
on posterior arch of atlas, lying in the suboccipital triangle, and pierces the 
occipito-atloid ligament and dura mater — and passes into cranium through 
foramen magnum — upward upon lateral aspect of medulla to its anterior 
aspect, where it unites with its fellow to form the basilar. 

Relations. — (a) First or Cervical Part : — from origin to transverse 
process of sixth cervical vertebra, lying between scalenus anticus and longus 
colli. Anteriorly — vertebral vein; internal jugular vein; inferior thyroid 
artery; thoracic duct (left side). Posteriorly — transverse process of seventh 
cervical vertebra; sympathetic nerve. Externally — scalenus anticus. In- 
ternally — longus colli, (b) Second or Vertebral Portion : — runs in osseo- 
muscular canal formed by intervertebral foramina and intertransverse muscles, 
surrounded by plexus of veins and branches of sympathetic nerve, (c) 
Third or Occipital Portion : — lies in suboccipital triangle, which is formed, 
superiorly and internally, by rectus capitis posticus major; superiorly and 
externally, by obliquus capitis superior; inferiorly and externally, by obliquus 
capitis inferior; covered by complexus muscle; and floor formed by posterior 
occipito-atlantal ligament, posterior arch of atlas and posterior atlanto- 
axial ligament; — the triangle containing the vertebral artery and suboccipital 
nerve, the latter passing between the artery and arch of the atlas. Ante- 
riorly — rectus capitis lateralis; articular process of atlas; occipito-atloid 
ligament. Posteriorly — superior oblique; rectus capitis posticus major; 
complexus. (d) Fourth or Intracranial Portion: — from opening in dura 
to lower border of pons, where it unites with its fellow to form basilar 
artery. 

Indications for Ligation. — Wounds; traumatic aneurism; in connection 
with ligation of innominate (to prevent secondary hemorrhage). 

Sites of Ligation. — In the first or cervical portion (usual site); in third 
or occipital portion (rarely). 



LIGATION OF VERTEBRAL BRANCH OF SUBCLAVIAN 

NEAR ITS ORIGIN. 

Position. — Patient supine; shoulders raised; neck prominent; head to 
opposite side; surgeon on right, in operating on either vertebral. 
Landmarks. — Anterior border of sternomastoid. 



56 OPERATIONS UPON THE ARTERIES. 

Incision.- — About 7.5 cm. (3 inches) in length, extending along the ante- 
rior border of the sternomastoid, ending below at the clavicle. (As for ligation 
of the common carotid below the omohyoid.) 

Operation. — (1) Having divided skin, superficial fascia, and the anterior 
portion of the platysma, branches of the superficial cervical nerve, and com- 
municating veins between the anterior and external jugular veins, are en- 
countered and are treated as indicated. (2) Incise the deep cervical fascia, 
exposing the anterior border of the sternomastoid, which is to be drawn 
outward; and the omohyoid, which is to be retracted downward and inward; 
and also the sternohyoid, which is drawn inward. (3) Having freed the 
attachment of the inner aspect of the common sheath, the carotid, internal 
jugular, and pneumogastric are drawn outward from over the vertebral 
artery. The prevertebral fascia is then incised vertically between the carotid 
tubercle (transverse process of sixth cervical vertebra) and the arch of the 
inferior thyroid artery (where it turns inward to the posterior surface of the 
thyroid gland) — where the vertebral artery will be found ascending, partly 
covered by the longus colli, to the foramen in the transverse process of the 
sixth cervical vertebra, having the anterior scalenus muscle and phrenic 
nerve to its outer side, and the longus colli muscle and recurrent laryngeal 
nerve to its inner side, and the inferior thyroid artery and vein and the vertebral 
vein lying over it. All these structures, therefore, are to be displaced in the 
most convenient directions, as the finger seeks the vertebral artery in the 
above triangular space. The pleura lies below and internally. The thoracic 
duct, on the left, crosses the artery from within outward. (4) The artery is 
to be exposed, and the ligature passed with especial care, in order to avoid, 
as far as possible, the fibers of the sympathetic, some of which are apt to be 
included in the ligature. (Also see Fig. 12, M.) 

Comment. — The vertebral artery may also be ligated bv an incision 
made along the posterior border of the sternomastoid, followed by the inward 
retraction of that muscle (with or without a partial division of its clavicular 
attachment), but is less simple than the above. The artery may also be 
ligated in the suboccipital triangle. 



SURGICAL ANATOMY OF INFERIOR THYROID BRANCH OF THYROID 
AXIS OF SUBCLAVIAN ARTERY. 

Description and Relations. — Largest branch of thyroid axis (which 
latter arises from first part of subclavian). Ascends upward and inward 
to posterior surface of thyroid gland — passing behind common carotid, internal 
jugular, pneumogastric nerve, and sympathetic nerve (middle cervical gan- 
glion usually resting upon it) — and in front of vertebral artery, recurrent 
laryngeal nerve (sometimes posterior to it), longus colli muscle. The thoracic 
duct passes in front of commencement of left vertebral artery. 

Indications for Ligation. — Preliminary to thyreoidectomy; and to 
diminish goiter. 

Sites of Ligation. — Just beyond the ascending cervical branch (which 
arises shortly before the vertebral passes behind the carotid). 



SURGICAL ANATOMY OF INTERNAL MAMMARY. 57 

LIGATION OF INFERIOR THYROID BRANCH OF THYROID AXIS OF 

SUBCLAVIAN. 

Position. — Patient supine; shoulders elevated; neck prominent; head to 
opposite side. Surgeon to right side, in either case. 

Landmarks. — Anterior border of sternomastoid. 

Incision. — About 7.5 cm. (3 inches) in length, along the anterior margin 
of the sternomastoid (as for the common carotid). 

Operation. — Divide skin, superficial fascia, and the platysma, when 
branches of the superficiaiis colli nerve and tributaries between the anterior 
and external jugular veins are met, and are to be dealt with as indicated. 
Incise the deep cervical fascia and define the anterior border of the sterno- 
mastoid, and retract that muscle outward — the omohyoid is drawn downward 
and inward, and the sternohyoid inward. After freeing the inner attachment 
of the common sheath, the carotid, internal jugular, and pneumogastric are 
drawn outward from over the inferior thyroid artery. The artery is then 
sought by continuing the dissection toward the .vertebra?, lying a little way 
below the carotid tubercle, in the interval covered by the sternothyroid muscle, 
between the inner border of the retracted carotid sheath and the outer border 
of the thyroid gland. The gland is raised and displaced inward. The 
artery is exposed where it arches inward, and where the ascending cervical 
branch arises. The ligature is applied just beyond this branch — thus avoid- 
ing the recurrent laryngeal nerve, which runs along the trachea and behind 
the thyroid gland; and the vertebral artery, nearly parallel with it below 
and passing behind the inferior thyroid as the latter bends inward. The 
sympathetic nerve, which sometimes embraces the artery, and the phrenic, 
which lies to its outer side, are to be guarded against injury. 

SURGICAL ANATOMY OF INTERNAL MAMMARY BRANCH OF SUB- 
CLAVIAN. 

Description. — Arises from lower aspect of first part of subclavian, near 
to inner margin of scalenus anticus — descends forward and inward, passing 
behind clavicle to enter thorax posterior to cartilage of first rib — thence 
runs downward parallel with and about 1.3 cm. (h inch) external to margin 
of sternum, to interspace between sixth and seventh costal cartilages, where 
it divides into superior epigastric and musculophrenic. Its two vena? comites 
unite to form one trunk in first intercostal space and empty into the innominate 
vein. The internal mammary artery, above, is 0.5 to 1.5 cm. (i- to f inch) 
from border of sternum — and, below, from 1 to 2 cm. (f- to A inch) from the 
sternal margin. In its upper part it lies between the internal intercostal 
muscle and costal cartilages, in front; and pleura behind. In its lower part 
it lies between the costal cartilages in front; and triangularis sterni behind 
(the latter structure intervening between it and the pleura). 

Relations. — (a) Cervical Part : — Covered by sternomastoid, subclavian 
vein, internal jugular vein, phrenic nerve. Rests on pleura, innominate 
vein, (b) Thoracic Part : — Covered by cartilages of first to sixth ribs, pecto- 
ralis major, internal intercostal muscles, anterior intercostal membrane. 
Rests on pleura (above), and triangularis sterni (below). 

Arterial Supply of the Antero-lateral Thoracic Wall. — (a) As the 
internal mammary artery crosses the upper intercostal spaces two branches 
(superior and inferior anterior intercostal arteries, or superior and inferior 
branches of the anterior intercostal arteries, where they arise from a common 
trunk) are given off in each of the five or six upper interspaces — which pass 
outward between the pleura and the internal intercostal muscles, and then 



58 



OPERATIONS UPON THE ARTERIES. 



between the internal and external intercostal muscles, running along the 
lower border of the superior, and the upper border of the inferior rib — to 
anastomose with the superior and inferior branches of the aortic intercostals. 
(b) In each of the same upper five or six spaces a single branch, the perforating, 
or the anterior perforating, is given off between the upper and lower anterior 
intercostal arteries — which pierce the internal intercostal muscles, between 
the costal cartilages, and supply the pectoralis major, mammary gland (sec- 
ond, third, and fourth branches), and skin, (c) The anterior intercostal 
branches for the five or six lower interspaces are given off by the mus- 
culophrenic branch, which passes down behind the costal cartilages, pierc- 
ing the diaphragm opposite the ninth rib, and ending at the tenth or eleventh 
interspace by anastomosing with the ascending branch of the deep circumflex 
iliac. The anterior intercostals anastomose with the lower aortic intercostals. 
(See Surgical Anatomy of Aortic Intercostal Arteries, page 76.) 

Indications for Ligation. — Rare, except for wound, when it is usually 
ligated at the site of injury. If the artery have retracted out of reach, it is 
ligated in the interspace above or below. 

Sites of Ligations. — Reached most readily in first, second, or third 
interspaces — especially in the second. 




A CFG 

Fig. 22.— Ligation of Right Internal Mammary in Second Intercostal Space:— A, Pec- 
toralis major; B, External intercostal muscle, continued to sternum by anterior intercostal mem- 
brane; C, Internal intercostal muscle; D, Margin of sternum; E, Endothoracic fascia; F, Pleura; 
G, Internal mammary artery and venae comites. 



LIGATION OF INTERNAL MAMMARY BRANCH OF SUBCLAVIAN 

IN SECOND INTERCOSTAL SPACE. 

Position. — Patient supine; chest supported from behind (to increase 
width of intercostal spaces). Surgeon on side of operation. 

Landmarks. — Outer border of sternum; lower border of second and 
upper border of third costal cartilages. 



SURGICAL ANATOMY OF AXILLARY ARTERY. 



59 



Incision. — Transverse in direction and about 6.3 cm. (2J inches) in 
length — beginning over center of sternum and passing outward over center 
of interspace between second and third costal cartilages (Fig. 10, V). 

Operation. — Divide skin, fascia, pectoralis major, anterior intercostal 
membrane (running downward and inward), internal intercostal muscle 
(running downward and outward), and endothoracic fascia — when the artery 
is found lying upon the pleura, with the venae comites to either side. Separate 
the artery and pass the needle with especial care, to avoid the pleura (Fig. 58). 





W « 



Fig. 23. — Incisions for Ligating Right Axillary and Brachial Arteries: — A, Junction 
of anterior and middle thirds of outer axillary wall ; B, Center of bend of elbow ; C, Ligation of third 
part of axillary ; D, Of brachial in middle of arm ; E, Of brachial at bend of elbow. 



SURGICAL ANATOMY OF AXILLARY ARTERY. 

Description and Relations. — Continuation of subclavian — extending 
through axilla, from lower border of first rib, on to the arm, at the lower 
border of the tendon of teres major muscle, where it becomes the brachial. 
It is divided into three parts: (a) First Part : — About 2.5 cm. (1 inch) in length 
— extending from lower border of first rib to upper border of pectoralis 
minor, having following relations: Anteriorly — skin; superficial fascia; 
origin of platysma; deep fascia; pectoralis major; clavicle (when shoulder is 
depressed) ; subclavius muscle (when shoulder is depressed) ; costocoracoid 
membrane; layer of areolar fatty tissue; cephalic vein; acromiothoracic vein; 
anterior external thoracic nerve; axillary lymphatic trunk. Posteriorly — 
first intercostal space; first intercostal muscle; second (and sometimes third) 
serrations of serratus magnus; part of second rib; posterior thoracic nerve. 
Externally — brachial plexus. Internally — axillary vein; anterior internal 
thoracic nerve, (b) Second Part : — about 3 cm. (i| inches) in length — 
lying behind pectoralis minor muscle, and having following relations: Ante- 



60 OPERATIONS UPON THE ARTERIES. 

riorly — integuments; superficial fascia; pectoralis major; pectoralis minor. 
Posteriorly — posterior cord of brachial plexus; areolar tissue and fat; sub- 
scapularis. Externally — external cord of brachial plexus; coracoid process 
(somewhat removed). Internally — internal cord of brachial plexus; axillary 
vein, (c) Third Part: — about 7.5 cm. (3 inches) in length — extending from 
lower border of pectoralis minor to lower border of tendon of teres major 
(the upper half being in axilla, the lower half on arm), and having following 
relations: Anteriorly — integument; superficial fascia; pectoralis major; deep 
fascia of arm; internal root of median nerve; external brachial vena comes. 
Posteriorly — musculospiral nerve; circumflex nerve; fatty areolar tissue; 
subscapulars ; latissimus dorsi; teres major. Externally — external root of 
median nerve; musculocutaneous nerve; coracobrachialis. Internally — in- 
ternal root of median nerve; ulnar nerve; internal cutaneous nerve; lesser 
internal cutaneous nerve; axillary vein. 

Branches. — From first part — superior thoracic, acromial thoracic. 
From second part — long thoracic, alar thoracic. From third part — sub- 
scapular, anterior circumflex, posterior circumflex. 

Line of Artery. — (With arm at right angle to trunk and hand supine) — 
from middle of clavicle to junction of anterior and middle thirds of the 
outer axillary wall, between the anterior and posterior folds of the axilla. 

Sites of Ligation. — Third part, by preference; — first part, if third part 
not available. Ligation of third portion of subclavian is usually considered 
preferable to that of first part of axillary (Figs. 23, C, and 10, W). 

Comment. — (1) When the arm is at a right angle to the body, the axillary 
vein is drawn across the first part of the artery. (2) The upper and lower 
borders of the pectoralis minor correspond, respectively, with lines drawn 
from the junction of the third rib and its cartilage to the coracoid process; 
and from the junction of the fifth rib and its cartilage to the coracoid process. 
(3) Two brachial venae comites are generally found at the lower part of the 
artery — and also the basilic vein, unless it have already joined the internal 
vena comes. 

LIGATION OF FIRST PART OF AXILLARY ARTERY 

PA' CURVED TRANSVERSE INCISION BELOW CLAVICLE. 

Position. — Patient on back, at edge of table; upper thorax raised; shoulder 
backward. Surgeon near thorax on left, for left operation; near head on 
right, for right operation — (or between abducted limb and body on each 
side). 

Landmarks. — Clavicle; sternoclavicular articulation; coracoid process. 

Incision. — Curved incision in infraclavicular fossa — beginning just ex- 
ternal to the sternoclavicular joint — dipping, at lowest point, about 1.3 cm. 
(^inch) below clavicle — and ending at the coracoid process (Fig. 10, W). 

Operation. — Incise skin, platysma, supraclavicular nerves, and fascia. 
Carefully guard the cephalic vein and branches of acromial thoracic artery 
at outer part of wound, on account of collateral circulation. Divide the clavic- 
ular origin of the pectoralis major throughout the wound. Clear the areolar 
tissue beneath the pectoralis major. Expose the upper border of the pectoralis 
minor and draw it downward. Divide obliquely downward and outward, near 
the coracoid process, the costocoracoid membrane — through which pass the 
cephalic vein, branches of the acromiothoracic artery, and the anterior thoracic 
nerves — and displace it upward and outward. The cephalic vein, indicating 
the position of the axillary vein, is generally closely adherent to the costocora- 



LIGATION OF FIRST PART OF AXILLARY ARTERY. 



6l 



coid membrane. Expose the sheath and clear the artery — which lies between 
the axillary vein on the inner side and the brachial plexus on the outer, aided 
in the exposure by bringing the arm nearer the body, when the axillary vein 
will be carried from over the artery to its inner side. The ligature is placed 
above the acromiothoracic branch. The incised pectoralis major muscle 
is repaired by gut suturing. 

Comment. — This is the easiest and most frequent ligation of the first part 
in the rare cases in which a ligation at this site is done — a ligation of the third 
portion of the subclavian being considered preferable. The first part may also 
be exposed by an oblique incision in the groove between the pectoralis major 
and deltoid. 

Collateral Circulation. — When ligated between the superior thoracic 
and acromial thoracic: — Suprascapular and posterior scapular; with acromial 
thoracic and subscapular. Internal mammary, aortic intercostals, superior 
intercostal; with long thoracic and subscapular. Plexiform vessels from 
subclavian; with plexiform vessels from axillary. 




Fig. 24. — Ligation of Third Part of Right Axillary: — A, Coracobrachial (retracted 
outward); B, Pectoralis major; C, Teres major; D, Triceps; E, Axillary artery; F, Basilic vein, 
becoming axillarv vein after receiving two brachial venae comites; G, Right brachial vena 
comes; H, Musculocutaneous nerve; 1, Median X.; S, Internal cutaneous X.; K, K, Ulnar N. 



62 



OPERATIONS UPON THE ARTERIES. 



LIGATION OF THIRD PART OF AXILLARY ARTERY. 

Position. — Patient supine at edge of table; shoulders raised; arm at 
right angle to body, and slightly rotated outward. Surgeon between arm 
and chest, on either side. Axilla to be shaved. 

Landmarks. — Junction of anterior and middle thirds of external axillary 
wall; coracobrachialis. 

Incision. — About 7.5 cm. (3 inches) in length — beginning at the middle 
of the outlet of the axilla, at the junction of the anterior and middle thirds 
of its outer wall, and passing downward along the inner border of the coraco- 
brachialis (Fig. 23, C). 




Fig. 25. — Cross-section of the Right Arm at the Axillary Level: — A, Axillary 
artery and vein; B, Ulnar nerve; C, Musculospiral nerve; D, Median nerve; E, Internal cutaneous 
nerve; F, Musculocutaneous nerve; G, Coracobrachialis muscle; H, Biceps; I, Pectoralis major 
muscle and biceps tendon; J, Deltoid; K, Triceps; L, L, Latissimus dorsi. (The cross-section 
modified from Esmarch.) 

Operation. — Having incised integument and fascia, expose the inner 
border of the coracobrachialis (Fig. 24). Draw this muscle and the musculo- 
cutaneous nerve outward. The median nerve is exposed and also drawn 
outward. The internal cutaneous and ulnar nerves are drawn inward. Venae 
comites are generally present at the lower part of the axilla and sometimes 
the basilic vein, which have to be guarded. Again, the axillary vein alone 
may be present to the inner side of the artery. Pass the needle from the vein, 
ligating the artery as far from a large branch as possible (Fig. 25). 



SURGICAL ANATOMY OF BRACHIAL ARTERY. 



63 



Collateral Circulation. — (a) If tied below the circumflex arteries: — the 
posterior circumflex above, with the superior profunda below, (b) If tied 
between subscapular above and two circumflex branches below: — the supra- 
scapular and acromial thoracic above, with posterior circumflex below. 



SURGICAL ANATOMY OF BRACHIAL ARTERY. 

Description. — Continuation of axillary artery. Extends down inner 
and anterior aspect of arm, from lower border of tendon of teres major to 
about 1.3 cm. (^ inch) below center of crease at bend of elbow, and divides, 
opposite junction of head with neck of radius, into radial and ulnar arteries. 
The artery lies in the depression at the inner borders of the coracobrachialis 
and biceps, and then in the groove between the supinator longus and pronator 
radii teres, passing under the bicipital fascia below. It lies to the inner side 
of humerus above, and in front of it below. 




Fig. 26.— Ligation of Right Brachial at Middle of Arm :— A, Biceps; B, Coracobrachi- 
alis (retracted outward) : C, Triceps; D, Brachial artery and branches; E, Brachial venae comites 
and communicating branches ; F, Basilic vein ; G. Branch from basilic to cephalic vein ; H, Median 
nerve; I, Ulnar X. ; J, Internal cutaneous N. 

Relations. — Anteriorly: integument; superficial and deep fascia; 
median nerve (in middle); median basilic vein and bicipital fascia (at elbow). 
Posteriorly : lies, in order, upon — long head of triceps (musculospiral nerve 
and superior profunda artery intervening); inner head of triceps; insertion 
of coracobrachialis; brachialis anticus. Externally: in order — coraco- 
brachialis; belly of biceps (both slightly overlapping the artery); tendon of 



6 4 



OPKRATIONS UPON THE ARTERIES. 



biceps; median nerve, above (crossing artery at middle); external vena comes. 
Internally: internal cutaneous and ulnar nerves (above); median nerve 
(below); internal vena comes; basilic vein. 

Branches. — Superior profunda; inferior profunda; anastomotica magna; 
nutrient; muscular. 

Line of Artery. — (Arm extended and abducted, hand supine.) From 
junction of anterior and middle thirds of outer wall of axilla to center of 
bend of elbow (Fig. 23, A and B). 

Sites of Ligation. — Middle of arm (preferably); bend of elbow. 




Fig. 27. — Cross-section of the Middle of the Right Arm: — A, Brachial artery and 
veins and inferior profunda artery and median and ulnar nerves; B, Musculospiral nerve and 
superior profunda artery; C, Nutrient vessels; D, Biceps muscle; E, Triceps; F, Brachialis anticus 
muscle. (Cross-section modified from Braune.) 



LIGATION OF BRACHIAL ARTERY 

IN MIDDLE OF ARM. 

Position. — Limb extended, abducted, and hand supine. Surgeon to 
outer side of limb, cutting from above downward on right, and from below 
upward on left. 

Landmarks. — Inner border of coracobrachialis and biceps; line of 
artery. 

Incision. — About 5 to 7.5 cm. (2 to 3 inches) in length, extending along 
inner border of biceps, in line of artery, opposite middle of arm (Fig. 23, D). 

Operation. — The skin and fascia having been divided, the inner border 
of the biceps must be clearly recognized and retracted outward — when the 
arterv is generally found under its inner margin — the median nerve usually 
crossing the front of the arterv at its middle — the internal cutaneous nerve 



LIGATION OF BRACHIAL ARTERY. 



65 



lying to the inner side (Fig. 26). The venae comites and basilic vein are to 
be separated from the artery. The needle is passed from the nerve (Fig. 27). 
Comment. — (1) The artery is not as easily found in this situation as 
the superficial position would suggest. Its exposure is made easier by an 
assistant's holding the limb by the wrist, so that it cannot rest on the table, 
where the triceps is apt to be pushed upward and may protrude the inferior 
profunda artery and ulnar nerve, instead of the brachial artery and median 
nerve (Heath). (2) In ligating higher than the middle third, the artery 
lies to the inner side of the coracobrachialis, the median nerve to the outer 
side, and the ulnar nerve to the inner. 




Fig. 28. — Ligation of the Right Brachial at the Bend of the Elbow: — A, A, Median 
basilic vein; B, Median cephalic vein; C, Internal cutaneous nerve and branches; D, Biceps; 
E, E, Bicipital fascia; F, Brachial artery; G, Brachial venae comites and communicating branch; 
H, Median nerve; I, Brachialis anticus muscle. 



LIGATION OF BRACHIAL ARTERY 

AT BEND OF ELBOW. 

Position. — Limb extended (not overextended) and abducted. Surgeon 
to outer side of limb, cutting from above on right, and from below on left. 

Landmarks. — Inner border of biceps tendon. 

Incision. — About 5 cm. (2 inches) in length — in the internal bicipital 
fossa, along the inner border of the biceps tendon — its center corresponding 
to the " fold of the elbow." This incision will be oblique and its upper end 
will commence opposite the tip of the internal condyle of the humerus. It is 
well to compress the veins above, to get an idea of their position at the elbow, 



66 



OPERATIONS UPON THE ARTERIES. 



and thus avoid them, if possible. Ordinarily the incision will lie above and 
to the outer side of the median basilic (Fig. 23, E). 

Operation. — Having incised skin and superficial fascia, isolate the median 
basilic vein and accompanying internal cutaneous nerve and retract them 
inward (Fig. 28). Incise, in the direction of the original wound, the deep 
fascia and the bicipital fascia — the latter (passing inward and downward) 
is to be incised to as limited an extent as possible. Beneath the bicipital fascia 
lies the artery, with its vense comites — the median nerve generally lying out 
of the way and to the inner side, nearer the upper than the lower part of the 




Fig. 20 — Cross-section of Right Arm just below the Elbow-joint : — A, Brachial 
artery dividing into radial and ulnar, with vena; comites; B, Median basilic vein; C, Radial 
recurrent artery and radial and interosseous nerves; D, Ulnar nerve and posterior ulnar recurrent 
artery; E, Median nerve and anterior ulnar recurrent artery; F, Biceps tendon; G, Supinator 
longus muscle; H, Extensor carpi radialis longior; I, Extensor carpi radialis brevior; J, Extensor 
carpi ulnaris; K, Anconeus; L, Pronator radii teres; M, Flexor sublimis digitorum; N, Flexor 
carpi ulnaris (a fascial line is seen between its two parts). The brachialis anticus muscle lies 
just below the brachial artery. The flexor carpi radialis lies just to the right of the pronator 
radii teres. (The cross-section modified from Braune.) 



wound. Pass the needle from the side of the ulnar nerve, 
bicipital fascia with gut (Fig. 29). 



Resuture the 



SURGICAL ANATOMY OF RADIAL ARTERY. 

Description. — Smaller but more direct of two divisions of brachial. 
Begins at bifurcation of brachial, about 1.3 cm. (J inch) below bend of elbow 
— runs outward and downward along radial side of forearm to styloid process 
of radius — thence passes around outer side of carpus over external lateral 
ligament and beneath extensor tendons of thumb, to back of wrist — and 
enters palm between first and second metacarpal bones, passing between 
the two heads of first dorsal interosseous muscle — thence crosses metacarpal 



SURGICAL ANATOMY OF RADIAL ARTERY. 67 

bones and interossei muscles, anastomosing at ulnar side of hand with deep 
branch of ulnar, to form deep palmar arch. The artery is accompanied by 
two vena? comites. 

Relations. — (a) In Forearm : — The artery runs in outermost intermuscu- 
lar space, lying between supinator longus and pronator radii teres above, and 
between supinator longus and tendon of flexor carpi radialis below. Ante- 
riorly — skin; fascia; supinator longus (above). Skin; fascia; cutaneous 
vessels and nerves (below). Posteriorly — (from above downward) tendon 
of biceps; supinator brevis; insertion of pronator radii teres; radial origin 
of flexor sublimis digitorum; flexor longus pollicis; pronator quadratus; 
anterior surface of lower end of radius. Externally — supinator longus 
(guide to arterv) and external vena comes (throughout) ; radial nerve (middle 
third). Internally — pronator radii teres (upper third); tendon flexor carpi 
radialis (lower third); internal vena comes (throughout), (b) At Wrist: — 
The artery winds over outer side of carpus, from a point just below and 
internal to stvloid process of radius, to base of first interosseous space, entering 
the palm between the two heads of the first dorsal interosseous muscle (ab- 
ductor indicis) to form the deep palmar arch. It is covered, successively, 
by extensor ossis metacarpi pollicis; extensor brevis pollicis; branches of 
radial nerve; superficial radial veins; extensor longus pollicis; — and rests, in 
order, upon external lateral ligament; scaphoid; trapezium; base of first 
metacarpal; dorsal carpal ligaments. It is accompanied by two vena? comites 
and branches of musculocutaneous nerve, (c) In the Palm : — Enters palm 
in upper part of interval between first and second metacarpals, passing 
between two heads of first dorsal interosseous muscle (abductor indicis) — 
runs inward between adductor obliquus pollicis and adductor transversus 
pollicis — crossing the palm transversely, with slight downward curve, to 
base of metacarpal of little finger, and there anastomoses with deep branch 
of ulnar, forming the deep palmar arch. The deep palmar arch, therefore, 
extends from base of first interosseous space to base of metacarpal of little 
finger, and is about 2 cm. (f inch) nearer the wrist than is the superficial 
palmar arch. It is covered by the superficial and deep flexor tendons; ad- 
ductor obliquus pollicis; part of flexor brevis minimi digiti; part of opponens 
minimi digiti; lumbricales. It rests upon adductor transversus pollicis; 
carpal extremities of metacarpal bones; interossei muscles. It is accom- 
panied by two vena? comites and the deep branch of the ulnar nerve (running 
in opposite direction). 

Branches. — (a) In Forearm — radial recurrent; muscular; anterior radial 
carpal; superficialis vola?. (b) At Wrist — posterior radial carpal; metacarpal 
(first dorsal interosseous); dorsalis pollicis; dorsalis indicis. (c) In Palm 
— princeps pollicis; radialis indicis; palmar interosseous; recurrent; per- 
forating. 

Line of Artery. — (a) In Forearm (with hand supine) — from center of 
bend of elbow, to inner side of forepart of stvloid process of radius (Fig. 
30, H and I), (b) At Wrist — from inner side of forepart of styloid process 
to base of first interosseous space, (c) In Palm — runs about 2 cm. (f 
inch) nearer wrist than does superficial palmar arch (which corresponds 
with a line continued across on level with lower border of outstretched 
thumb). 

Sites for Ligature. — Upper forearm (rarely); middle forearm; lower 
forearm (preferably); back of hand (rarely). In palm — the arch may be 
tied in case of wounds, under which circumstances it may be ligated at any 
site (Fig. 30, A, B, C, D). 

Anatomy of the " Tabatiere," or " Snuff-box." — The triangular 



68 



OPERATIONS UPON THE ARTERIES. 



space on back of hand — bounded, on radial side, by extensor ossis metacarpi 
pollicis, and extensor brevis pollicis; — on ulnar side, by extensor longus polli- 
cis; — above, by lower edge of posterior annular ligament. Its floor is 
formed by trapezium, part of scaphoid, base of first metacarpal. It con- 
tains radial artery, cephalic vein of thumb, branch of internal division of 
radial nerve, branch of musculocutaneous nerve. 




Fig. 30.— Incisions for Ligating Right Radial and Ulnar Arteries, and Superficial 
and Deep Palmar Arches :— A, Ligation of radial in upper third of forearm ; B, of radial in middle 
third; C, of radial in lower third; D, of deep palmar arch ; E, Ligation of ulnar in middle third of 
forearm; F, of ulnar in lower third ; G, of superficial palmar arch; H, Center of bend of elbow ; I, 
Antero-internal aspect of styloid process of radius; J, Radial sideof pisiform bone; K, Anterior aspect 
of inner condyle of humerus; L, Point on inner aspect of forearm at junction of upper and middle, 
thirds. 



LIGATION OF RADIAL ARTERY. 



69 




Fig. 31. — Ligation of the Right Radial Artery in the Upper Part of the Forearm: 
— A, Radial artery; B, Radial vena? comites; C, Radial nerve; D, Supinator longus muscle; 
E, Pronator radii teres muscle; F, Flexor carpi radialis muscle. (Modified from Deaver.) 



LIGATION OF RADIAL ARTERY 

IN UPPER THIRD OP" FOREARM. 

Position. — Hand supine; wrist extended. Surgeon stands outside of 
limb, cutting downward on right and upward on left. Assistant holds fingers 
with one hand and grasps forearm with other. 

Landmarks. — Line of artery; inner border of supinator longus. 

Incision. — From 5 to 7.5 cm. (2 to 3 inches), in line of artery — with 
center over the point to be tied (Fig. 30, A). 

Operation. — Having incised skin and superficial fascia, the radial or 
median vein may be met. Divide the deep fascia and open up the space 
between the supinator longus (fibers running directly downward) and the 
pronator radii teres (fibers running downward and outward) (Fig. 31). The 
artery lies under the edge of the supinator longus and upon the inser- 
tion of the pronator radii teres. The radial nerve lies well to the outer 
side. 

Comment. — Unless one recognize the inner margin of the supinator 
longus, there is possibility of hitting off the wrong intermuscular septum and 
getting too near the middle of the forearm. The anterior surface of the 
supinator longus (and not its. inner border) appears at first, in operating upon 



7o 



OPERATIONS UPON THE ARTERIES. 



the muscular — and this must be well retracted outward. Note. — Ligation 
of the middle third of the radial amounts to a downward extension of the follow- 
ing operation {v. s.), or an upward extension of the following operation 
(v. i.). The vessel is found at the inner margin of the supinator longus, 
resting upon the flexor sublimis digitorum and tlexor longus pollicis. 




Fig. 32. — Cross-section of the Upper Third of the Right Forearm: — A, Radial 
artery and branches, veins, and nerve; B, Ulnar and interosseous arteries, veins, and median 
nerve; C, Ulnar nerve; D, Pronator radii teres muscle; E, Flexor carpi radialis; F, Subcutaneous 
vein and nerve, G, Flexor profundus digitorum; H, Flexor carpi ulnaris; I, Anconeus; J, Supinator 
longus; K, Extensor carpi radialis longior; L, Supinator brevis; M, Extensor carpi radialis 
brevior; N, Extensor communis digitorum; O, Extensor carpi ulnaris. (Cross-section modified 
from Braune.) 



LIGATION OF RADIAL ARTERY 

IN LOWER THIRD OF FOREARM. 

Position. — As for upper third. 

Landmarks. — Tendons of supinator longus and flexor carpi radialis. 

Incision. — From 2.5 to 5 cm. (1 to 2 inches), vertically, in center of interval 
between tendons of supinator longus and flexor carpi radialis (Fig. 30, C). 

Operation. — Having incised skin and superficial fascia, the radial vein, 
or a large branch, and often the superficialis volse artery, are met and are 
displaced to one side (Fig. 33). The deep fascia is divided, and the interval 
between the tendon of the supinator longus, externally, and the tendon of the 
flexor carpi radialis, internally, is opened up and the artery and its venae 
comites are found between them, accompanied by the anterior branch of 
the musculocutaneous nerve. 



LIGATION OF RADIAL ARTERY. 



71 




Fig. 33.— Ligation ok Lower Third of Right Radial (Jtst above Wrist) :— A, Radial 
vein; B, Anterior branch of musculocutaneous nerve; C, Supinator longus tendon ; D, Flexor carpi 
radialis tendon ; E, Pronator quadratus ; F, Radial artery ; G, Superficialis volae artery ; H, H, Radial 
venae comites. 




Fig. 34. — Cross-section of the Lower Third of the Right Forearm: — A, Radial 
artery and veins; B, Ulnar artery, veins, and nerve; C, Anterior interosseous artery; D, Posterior 
interosseous artery; E, Median nerve; F, Flexor sublimis digitorum muscle; H, Flexor digitorum 
profundus; I, Flexor longus pollicis; J, Pronator quadratus; K, Extensor indicis pollicis; L, 
Extensor proprius pollicis; M, Extensor indicis; X, Extensor communis digitorum; O, Supinator 
longus tendon; P, Flexor carpi radialis. (The cross-section modified from Braune.) 



7 2 



OPERATIONS UPON THE ARTERIES. 



r 




F'g- 35- — Ligation of Left Superficial and Deep Palmar Arches: — A, Annular liga- 
ment; B, Flexor brevis pollicis (part of its origin from annular ligament incised) ; C, Tendons of 
flexor sublimis digitorum and outer lumbrical (drawn inward); 1), Adductor obliquus pollicis; E, 
Adductor transversus pollicis; F, F, Branches of median nerve ; H, H, Superficial palmar arch ; G, 
Deep palmar arch and its vena; comites ; I, I, Superficial vein. 



LIGATION OF DEEP PALMAR ARCH OF RADIAL ARTERY. 

Position. — Limb supine; hand extended. Assistant steadying fingers 
and wrist. Surgeon cuts from above downward on both sides. 

Landmarks. — Oblique crease running downward and outward from 
junction of thenar and hypothenar eminences and partially circumscribing 
the thenar eminence. 

Incision. — From junction of the thenar and hypothenar eminences — and 
running along the thenar crease toward the metacarpo-phalangeal joint of 
the index-finger — with the center of the incision opposite the center of the 
ball of the thumb (Fig. 30, D). 



SURGICAL ANATOMY OF ULNAR ARTERY. 73 

Operation. — Having incised skin and superficial fascia, expose and 
ligate the superficial palmar arch (crossing the palm on a level with the lower 
border of the outstretched thumb) (Fig. 35). The muscles of the thenar 
eminence are now exposed, and these, with the annular ligament, are incised 
at the upper part of the wound to as limited an extent as possible. The 
interval between the flexor tendon of the index-finger and its accompanying 
lumbrical muscle, on the one hand, and the muscles of the thumb, on the 
other, is made out and opened up by deep retraction, guarding the branches 
of the median nerve. In the interval thus exposed by retraction is seen 
the adductor obliquus pollicis, which is to be divided vertically, w hen the 
arch will be found under it, running transversely from between the adductor 
obliquus pollicis and adductor transversus pollicis onto the deep fascia covering 
the interossei, and about 2 cm. (f inch) nearer the wrist than does the super- 
ficial arch. The needle is to be carefully passed in the deep wound, to avoid 
the nerves and veins. 

Comment. — The position for ligating can be located by feeling for the 
apex of the first interosseous space on the back of the hand. 



SURGICAL ANATOMY OF ULNAR ARTERY. 

Description. — Larger of two divisions of brachial artery. Begins at 
bifurcation of brachial, about 1.3 cm. (J inch) below bend of elbow, and in 
middle of forearm — runs through upper half of forearm, with slight curve 
(convexity to ulnar side), to ulnar aspect of limb, passing beneath the pronator 
radii teres and superficial flexors — thence vertically down the lower half 
of the forearm, along its ulnar border to the wrist, being slightly overlapped 
by the flexor carpi ulnaris. It crosses the annular ligament immediately 
to the radial side of the pisiform bone, and, entering the palm, divides into 
superficial and deep palmar branches, to help form superficial and deep 
palmar arches. It is accompanied by two vena? comites. The ulnar 
nerve comes into contact with the artery at the junction of its upper and 
middle thirds, and remains in relation with it to the palm, being upon its 
ulnar side. 

Relations. — (A) In Forearm: — Anteriorly — (a) Above — skin; fascia; 
superficial flexors (pronator radii teres, flexor carpi radialis, palmaris longus, 
flexor sublimis digitorum) ; median nerve (separated from artery by deep 
head of pronator radii teres), (b) Upper part of lower half — skin; fascia; 
and overlapped by tendon of flexor carpi ulnaris. (c) Lower part of lower 
half — skin; superficial fascia; deep fascia; palmar cutaneous branch of ulnar 
nerve. Posteriorly — brachialis anticus; flexor profundus digitorum. Ex- 
ternally — flexor sublimis digitorum (in lower two-thirds of artery's course). 
Internally — flexor carpi ulnaris (in lower two-thirds) ; ulnar nerve (in lower 
two-thirds). (B) At Wrist : — This part of the artery extends from the upper 
to the lower part of the annular ligament, running in a channel formed by 
the pisiform and unciform process of unciform bone and by expansion of 
flexor carpi ulnaris extending from pisiform to unciform process. Ante- 
riorly — skin; fascia; expansion of flexor carpi ulnaris from pisiform to unci- 
form process of unciform. Posteriorly — anterior annular ligament. Ex- 
ternally — unciform process of unciform bone. Internally — pisiform bone; 
ulnar nerve. (C) In Palm : — On entering the palm, the ulnar divides into 
superficial branch and deep branch: — (1) Superficial branch of ulnar — 
direct continuation of ulnar artery — descends short distance toward gap 



74 OPERATIONS UPON THE ARTERIES. 

between fourth and fifth fingers, thence curves outward (with convexity 
toward fingers) and anastomoses opposite gap between index and middle 
finger, and at junction of upper and middle thirds of hand, with superficialis 
vola? of radial (sometimes with branch from radialis indicis of radial) to 
form superficial palmar arch — having following relations: Anteriorly — 
skin; fascia; and, from ulnar to radial side, by palmaris brevis, palmar branch 
of ulnar nerve, palmar fascia, palmar branch of median nerve. Posteriorly 
— in order, from ulnar to radial side — annular ligament; short muscles of 
little finger; digital branches of ulnar nerve; superficial flexor tendons; digital 
branches of median nerve. (2) Deep (communicating) branch of ulnar 
artery — runs deeply inward, between abductor minimi digiti and flexor 
brevis minimi digiti — anastomosing with termination of radial to form deep 
palmar arch. 

Branches. — (a) In Forearm — anterior ulnar recurrent; posterior ulnar 
recurrent; common interosseous (anterior and posterior interosseous); mus- 
cular, (b) At Wrist — anterior ulnar carpal; posterior ulnar carpal, (c) 
In Palm — superficial palmar arch; deep (communicating) palmar. 

Line of Artery. — Upper third of artery corresponds with line from a 
point about 1.3 cm. (h inch) below center of bend of elbow, passing to inner 
side with gentle curve (convexity to ulnar side), to a point at junction of 
upper and middle thirds of following line. Lower two-thirds corresponds 
with line from anterior surface of internal condyle of humerus to radial 
side of pisiform bone (Fig. 30, H, L, and K, J). 

Sites for Ligation. — Upper third of forearm (rarely) ; middle third; lower 
third (commonly); superficial palmar arch (for wounds at that site). (Fig. 
3°-) 



LIGATION OF ULNAR ARTERY 

IN MIDDLE THIRD OF FOREARM. 

Position. — As for the radial artery. 

Landmarks. — Line of artery. The muscular landmarks at the middle 
of the forearm are generally difficult to recognize. 

Incision. — About 7.5 cm. (3 inches), in line of artery, with its center 
corresponding with the center of the forearm (Fig. 30, E). 

Operation. — Incise skin and superficial fascia. The anterior ulnar vein 
and anterior branch of internal cutaneous nerve are likely to be encountered 
(Fig. 36). Divide the deep fascia somewhat to the outer side of the skin 
incision, as the flexor sublimis digitorum is generally slightly overlapped by 
the flexor carpi ulnaris. In this deep fascia the intermuscular plane between 
the flexor carpi ulnaris and flexor sublimis digitorum is sought by exposure 
and by the sense of touch. A muscular branch will often lead to it. These 
muscles are retracted well apart, when the ulnar nerve is first encountered 
between them — and, following inward on the same plane, the artery will be 
found upon the flexor profundus, surrounded by the venae comites, and with 
the ulnar nerve to the ulnar side. 

Comment. — It is sometimes exceedingly difficult to hit off the intermuscular 
space, and even to find the artery when once in it. Remember that the anterior 
margin of the flexor carpi ulnaris slightly overlaps the flexor sublimis digitorum 
at this level. Also remember, when once in the intermuscular space, not to 
pass below the ulnar nerve, and thus go too deeply on the ulnar side of the 
forearm, but rather work inward from the level of the nerve. 



LIGATION OF ULNAR ARTERY. 



75 




Fig. 36. — Ligation of Right Ulnar in Upper Part of Middle Third: — A, Anterior 
ulnar vein; B, Anterior branch of internal cutaneous nerve; C, Flexor carpi ulnaris; D, Flexor 
sublimis digitorum; E, Flexor profundus digitorum; F, Ulnar nerve; G, Ulnar artery; H, Vena? 
comites. 




Fig- 37- — Ligation of Lower Third of Right Ulnar (Just above the Wrist): — A, 
Anterior ulnar vein; C, Tendon of flexor carpi ulnaris; D, Tendon of flexor sublimis digitorum: 
E, Ulnar artery; G, Ulnar vena; comites; H, Ulnar nerve. 



76 OPERATIONS UPON THE ARTERIES. 

LIGATION OF ULNAR ARTERY 

IN LOWER THIRD OF FOREARM. 

Position. — As for radial. 

Landmarks. — Outer border of flexor carpi ulnaris. 

Incision. — About 5 cm. (2 inches) in length— ending about 2.5 cm. 
(1 inch) above the pisiform bone — and placed between the tendon of the 
flexor carpi ulnaris and the innermost tendon of the flexor sublimis digitorum. 
(As the innermost tendon of the flexor sublimis digitorum is not always 
recognizable, the incision is generally placed to the outer side of the tendon 
of the flexor carpi ulnaris.) (Fig. 30, F.) 

Operation. — Having incised skin and superficial fascia, avoid the anterior 
ulnar vein or its branches (Fig. 37). Divide the deep fascia. Partly flex 
the wrist to relax the structures, and retract the flexor carpi ulnaris to the ulnar 
side. The artery will be found upon the flexor profoundus digitorum, with 
the venae comites closely surrounding it, and the ulnar nerve lying closely to 
the ulnar side. 

SURGICAL ANATOMY OF INTERCOSTAL BRANCHES OF THORACIC 

AORTA. 

Description. — The ten aortic intercostals generally supply from the 
third to eleventh intercostal spaces inclusive— the first space being supplied 
by superior intercostal alone — and the second space also by superior inter- 
costal alone, or conjointly by it and the first aortic intercostal. The tenth 
aortic intercostal runs below the twelfth rib (subcostal artery), (a) The Ver- 
tebral Portions of the Intercostal Arteries, arising in pairs from the posterior 
part of the thoracic aorta, pass around the vertebne — the right being covered 
by thoracic duct, vena azygos major, pleura, lung, esophagus— the left, 
by vena azygos minor, left superior intercostal vein, third vena azygos 
pleura, lung. The arteries here divide into posterior or dorsal, and anterior 
or intercostal branches, (b) The Intercostal Portions run forward and 
obliquely upward in the intercostal space to the lower border of the superior 
rib, and divide near the angle of the rib into upper (larger) and lower (smaller) 
branches — the former, to run in the groove along the lower border of the 
upper rib and anastomose with the superior intercostal branch of the internal 
mammary in the upper spaces, and of the musculophrenic in the lower — the 
latter, to run along the upper border of the lower rib and anastomose with 
the inferior branch of the internal mammary in the upper spaces, and of the 
musculophrenic in the lower. At first these arteries lie between pleurae, 
lungs, endothoracic fascia, and infracostals internally — and external inter- 
costal muscles externally — then (from the angles of the ribs) between the 
external and internal intercostal muscles. The sympathetic nerve crosses 
them opposite the head of the ribs. The intercostal vein lies above and 
the intercostal nerve below the intercostal arteries — except in the upper 
spaces. The arteries of the tenth and eleventh spaces run outward between 
the abdominal muscles. 

LIGATION OF AN INTERCOSTAL ARTERY 

BY AN INTERCOSTAL INCISION. 

Position. — Patient supine, and so turned as to render site of operation 
prominent, and chest supported below, so as to increase width of intercostal 
spaces. Surgeon stands on side of operation. Assistant opposite. 



LIGATION OF AN INTERCOSTAL ARTERY. 



77 



Landmarks. — Lower border of rib in the groove of which the special 
artery runs; or the upper border, in case it be the lower branch of the inter- 
costal artery. 

Incision. — About 5 cm. (2 inches), parallel with and just below the 
lower border of the indicated rib; or just above the upper border, as the 
case may be. 

Operation. — Incise skin and superficial fascia. As to what muscle, and 
as to what amount of muscle tissue, as well as fascia, will have to be further 
incised in the line of the original incision, before the intercostal muscles are 
reached, will depend upon the site at which the artery is to be exposed. Having 
passed through the overlying muscle-covering of the thoracic wall, the inter- 
costal fascia is met and incised, then the external intercostal muscle (if operat- 
ing anywhere between the tubercles of the ribs behind, and the costal car- 
tilages in front). The two cut margins of the external intercostals are then 
drawn upward and downward and the artery sought as it lies partially or 
entirely concealed in the inferior intercostal groove, with intercostal nerve 
below and vein above. The artery may be drawn out of its groove and down 
into view by the curved tip of the aneurism-needle. The vessel should be 
doubly ligated (its supply coming from both directions). The incised inter- 
costal muscle and fascia may be sutured with gut in closing the wound. 

Comment. — (1) If difficulty in exposing the artery be experienced, the rib 
may be exposed subperiosteally, as in the following operation. (2) It is to be 
remembered, in operating posterior to the angle of the rib, that the intercostal 
artery has not yet reached the inferior groove of the upper rib, but lies between 
the two ribs, and has not divided into its upper and lower branches. (3) If it 
be desired to ligate the upper and lower branches of the intercostal (anywhere 
between the angle and costal cartilages), the incision is made midway between 
the ribs, and, after retracting the cut external intercostal muscle, the upper 
branch is sought as above, and the lower branch is found along the upper 
border of the lower rib. Both are doubly ligated. The upper intercostal 
artery is often so small as to be difficult or impossible to find. 




Fig. 38. — Ligation of Left Intercostal Artery, in Lower Anterior Thoracic Region, 
by Partial Excision of a Rib: — A, Thoracic muscles; B, External intercostal muscle; C, Rib, 
with half-button of bone bitten out with rongeur forceps; D, Periosteum, incised over center of 
rib; E, Lower half of anterior layer of periosteum retracted downward ; F, F, Posterior layer oi peri- 
osteum incised and retracted upward and downward, showing intercostal vessels beneath; G, Inter- 
costal artery ; H, Intercostal vein ; I, Intercostal nerve. (Hartley's method.) 



78 OPERATIONS UPON THE ARTERIES. 

LIGATION OF AN INTERCOSTAL ARTERY 

BY PARTIAL, SUBPERIOSTEAL EXCISION OF RIB (HARTLEY'S METHOD.) 

Position — Landmarks. — As in the preceding operation. 

Incision.- — About 6 cm. (2^ inches), parallel with and directly over 
center of rib. 

Operation. — The above incision passes through skin, superficial fascia, 
any overlying thoracic muscles (according to site of operation), deep fascia and 
periosteum (Fig. 38). With periosteal elevator, free the lower half of the 
anterior surface, the inferior groove, and the lower half of the posterior sur- 
face of the rib, all subperiosteally. Then, with rongeur bone-forceps, bite 
out a "half -button" of bone from the bared lower half of the rib, being 
careful to insert the lower blade of the rongeur between the detached peri- 
osteum and the rib. After the half-button of bone is removed, the position 
of the artery is plainly evident— and the vessel is exposed by incising 
through the periosteal membrane, directly over it. 

Comment. — The artery may also be exposed by the ordinary method of 
subperiosteal excision of about 4 cm. (ij inches) of rib throughout its entire 
thickness. 



SURGICAL ANATOMY OF ABDOMINAL AORTA. 

Description. — Continuation of thoracic aorta. Commences at aortic 
opening of diaphragm, opposite lower border of twelfth dorsal vertebra — and 
passes down between pillars of diaphragm, in front of lumbar vertebrae, at 
first in median line, but deviating to left as it descends, until it lies a little 
to left of spine at its point of bifurcation, opposite lower border of fourth 
lumbar vertebra, where it divides into right and left common iliac arteries. 
Its point of bifurcation is represented externally, roughly, by a point about 
1.3 cm. (^ inch) below and a little to left of umbilicus — and, more accurately, 
by a line crossing the abdomen on a level with the highest points of the iliac 
crests. The accompanying vena cava is separated from the aorta above 
by the right crus of the diaphragm, and is on a plane anterior to it. Below, 
the vein lies in contact with the artery, and on a somewhat posterior plane. 
The artery is covered only by peritoneum at the site indicated for ligation, 
but between the serous covering and the artery lie important sympathetic 
nerve-cords from the aortic plexus (lying along the aorta between the superior 
and inferior mesenteric arteries) to the hypogastric plexus (lying between 
the common iliacs). 

Relations. — Anteriorly (from above downward, in order) : right lobe 
of liver; solar plexus; lesser omentum; termination of esophagus in stomach; 
ascending layer of transverse mesocolon; splenic vein (or beginning of vena 
portae); pancreas; left renal vein; third part of duodenum; mesentery; aortic 
plexus of sympathetic; spermatic (or ovarian) arteries; inferior mesenteric 
artery; median lumbar lymphatic glands and vessels; small intestines. Pos- 
teriorly: bodies of lumbar vertebrae; intervening intervertebral cartilages; 
anterior common ligament; left crus of diaphragm; left lumbar veins. To 
right: right crus of diaphragm; great splanchnic nerve; spigelian lobe of 
liver; receptaculum chyli (on a posterior plane); thoracic duct (on a posterior 
plane); right semilunar ganglion; inferior vena cava; vena azygos major. 
To left: left crus of diaphragm; left splanchnic nerve; left semilunar gan- 
glion; tail of pancreas; small intestines. 



LIGATION OF ABDOMINAL AORTA. 



79 



Branches. — (From above downward.) Phrenic, coeliac axis (gastric, 
hepatic, splenic); suprarenals; first lumbars, superior mesenteric; renals; 
spermatics (ovarians) ; second lumbars; inferior mesenteric; third lumbars; 
fourth lumbars; common iliacs; middle sacral. 

Line of Artery. — From a point in the anterior median line, on a level 
with the lower border of twelfth dorsal vertebra, to a point a little to left of 
umbilicus, on a level with the highest points of the iliac crests. 

Indications for Ligation. — Iliac and inguinal aneurisms and primary 
and secondary hemorrhage — in cases where no other means are possible. 
More than a dozen cases have been reported — one case living ten days. 

Sites for Ligation. — Between the origin of the inferior mesenteric (be- 
tween 2.5 and 5 cm., or 1 and 2 inches, above the bifurcation) and the bifurca- 
tion (Fig. 39). 




Fig- 39- — Incisions for Ligations in the Abdomino-pelvic Region:— A, Exposure of 
abdominal aorta by transperitoneal route, through median incision over umbilicus; B, Exposure of 
internal iliac, common iliac, and abdominal aorta by retroperitoneal route, through oblique incision 
parallel with Poupart's ligament ; C, Exposure of external, internal, and common iliacs by transperi- 
toneal route, through median incision below umbilicus ; D, of external and deep epigastric, retro- 
peritoneally, through oblique incision parallel with Poupart's ligament ; E, of common, internal, and 
external iliacs, transperitoneally, through vertical incision in linea semilunaris; F, of external iliac, 
transperitoneally, through intramuscular incision ; G, G, Anterior superior iliac spines; H, Symphysis 
pubis. 



LIGATION OF ABDOMINAL AORTA 

BV TRANSPERITONEAL .METHOD. 

Description. — The abdomen is opened in the median line, the intestines 
displaced, and the posterior parietal peritoneum opened over the artery. 

Position. — Patient supine; shoulders raised; knees slightly flexed. Surgeon 
on right. Assistant opposite. 



80 OPERATIONS UPON THE ARTERIES. 

Landmarks. — Median, vertical abdominal line; transverse line on level 
with highest points of iliac crests. 

Incision. — About 10 cm. (4 inches) in length, in linca alba, with its 
center corresponding with the umbilicus — the incision passing slightly to 
left of the navel, to avoid the round ligament of the liver and the urachus 

(Fig. 39, A). 

Operation. — The peritoneal cavity having been opened in the usual 
manner, the small intestines and. mesentery are well retracted upward and 
to the sides. Guided to the artery by its known position and by its pulsation, 
the peritoneum covering the vessel is carefully divided between the inferior 
mesenteric and its bifurcation in the iliacs. The clearing of the artery should 
be done with especial care, as inclusion of the sympathetic nerve-fibers (see 
Surgical Anatomy) is otherwise apt to take place — and is supposed to have 
been done in one case, which quickly ended fatally. A flat ligature should 
be used (kangaroo tendon, chromicized gut and silk, flat and round, have 
been used). The needle should be of special make and shape, and should 
be passed from the inferior vena cava. 

Comment. — This is the more desirable form of operation, though the 
case which survived longest was done through a posterior retroperitoneal 
incision. 

Collateral Circulation. — Internal mammary, above; with deep epi- 
gastric, below. Inferior mesenteric, above; with internal pudic, below. 
Possibly by lumbar arteries, above; with branches of internal iliac, below. 
And, if above the inferior mesenteric, by superior mesenteric, above; with 
inferior mesenteric, below. 



LIGATION OF ABDOMINAL AORTA 

BY RETROPERITONEAL OPERATION. 

Description. — The artery is here approached from the anterolateral 
abdominal region, the peritoneum being pushed back from the iliac vessels 
until the aorta is reached and exposed. 

Position — Landmarks — Incision — Operation. — The operation is prac- 
tically similar to that for the exposure and ligation of the common iliac extra- 
peritoneally, the site being reached by an extension of those steps (Fig. 39, B, 
except on left side, and Fig. 40). The patient is placed so as to be tilted toward 
the right side, the surgeon standing behind the patient, upon the side of the 
operation (the left). An extension of the incision employed for the common 
iliac is carried further upward to give the necessary room; and, if still required, 
additional room may be gotten by a second incision running parallel with the 
ribs, at a right angle to the main incision. The incision is made upon the 
left side — its general direction being from just within the anterior superior 
iliac spine toward the tip of the tenth rib — and the aorta is reached by following 
up the common iliac in the peeling back of the peritoneum from the iliac fascia 
The separation of the parts and exposure of the common iliac are, otherwise, 
the same as for the ligation of that vessel. The vessel is thus less satis- 
factorily exposed than by the intra-abdominal operation, and there is greater 
difficulty in avoiding the sympathetic nerve-cords that surround the vessel. 
The ligature is placed upon the same site as in the intra-abdominal operation, 
and the inferior vena cava is guarded in passing the needle. 



LIGATION OF COMMON ILIAC ARTERY. 8 1 

SURGICAL ANATOMY OF COMMON ILIAC ARTERIES. 

Description. — Arise from bifurcation of the abdominal aorta, opposite 
lower border of left side of body of fourth lumbar vertebra (corresponding, 
approximately, to a point about 1.3 cm. [h inch] below and a little to left of 
umbilicus — or, more accurately, on a level with a line passing transversely 
through the highest points of the iliac crests) — and pass thence downward 
and outward over the body of the fifth lumbar vertebra to margin of pelvis, 
bifurcating opposite upper border of sacro-iliac synchondrosis, into external 
and internal iliac arteries. The relations of right and left common iliacs 
differ slightly. 

Relations of Right Common Iliac Artery. — Anteriorly: peritoneum; 
right ureter (a little above its bifurcation) ; ovaries (in female) ; termination of 
ileum; terminal branches of superior mesenteric; branches of sympathetic 
to hypogastric plexus. Posteriorly: right common iliac vein; end of left 
common iliac vein; beginning of inferior vena cava; and, in less immediate 
relationship, the following — psoas magnus; sympathetic nerve; lumbosacral 
cord; obturator nerve; iliolumbar artery. Externally: beginning of inferior 
vena cava; end of right common iliac vein; psoas magnus. Internally: 
right common iliac vein; end of left common iliac vein; hypogastric plexus. 

Relations of Left Common Iliac Artery.— Anteriorly : peritoneum; 
small intestines; ureter; ovarian artery (in female); branches of sympathetic 
to hypogastric plexus; termination of inferior mesenteric artery; sigmoid 
flexure; sigmoid mesocolon; superior hemorrhoidal artery. Posteriorly: 
lower part of body of fourth lumbar vertebra; fifth lumbar vertebra; inter- 
vertebral discs; left common iliac vein; and, in less immediate relationship, 
the following — psoas muscle; obturator nerve; lumbosacral cord; iliolumbar 
artery. Externally: psoas muscle. Internally: left common iliac vein; 
hypogastric plexus; middle sacral artery. 

Branches. — Peritoneal; subperitoneal; ureteric; internal iliac; external 
iliac. 

Line of Artery. — Draw a line transversely across the abdomen, on 
level with highest points of iliac crests, which will cross the abdominal aorta 
at its bifurcation — draw a second line transversely across the abdomen on a 
level with the anterior superior iliac spines, which will cross the common 
iliacs at their bifurcation — draw a third line from a point on the first line about 
1.3 cm. (h inch) to the left of its center (which is the linea alba), to a point 
midway between the anttrior superior iliac spine and symphysis pubis. 
That portion of the third line between the two zones represents the common 
iliac— and that portion below the lower zone, the external iliac. The right 
common iliac is about 5 cm. (2 inches) in length; and the left, about 4.5 cm. 
(if inches). 

Site for Ligation. — As nearly midway of its length as possible. 



LIGATION OF COMMON ILIAC ARTERY 

BV RETROPERITONEAL OPERATION. 

Position. — Patient supine, or slightly turned to one side. The intes- 
tines are more easily displaced from the field of operation if the patient be 
in the Trendelenburg position. Surgeon stands upon side of operation. 
Assistant opposite. 

Landmarks. — Line of external iliac (v. s.); Poupart's ligament; anterior 
superior spine of ilium; eleventh rib. 
6 



82 



OPERATIONS UPON THE ARTERIES. 



Incision. — Begun as for exposure of external iliac (page 89) and con- 
tinued in the cleavage line of the external oblique as far upward toward 
the eleventh rib as necessary to furnish sufficient room (Fig. 39, B). 

Operation. — The steps of the operation are identical with those for 
exposure of the external iliac (page 89), with an extension upward, in the 
present operation, of the separation of the fibers of the external oblique 
and a division of the fibers of the internal oblique and transversalis as far 




Fig. 40. — Ligation of Right Common and Internal Iliacs, Retroperitoneally : — A, A, 
External oblique muscle and aponeurosis; B, Internal oblique; C, Transversalis; D, Conjoint ten- 
don ; E, E, Peritoneum retracted ; F, Ureter, retracted. ; G. Common iliac artery (sheath incised) ; H, 
Internal iliac artery (sheath incised) ; I, External iliac artery ; J, External and internal iliac veins; 
K, K, Deep epigastric artery ; L, Deep circumflex iliac artery; M, Lumbar artery ; N, Iliolumbar 
artery; O, Spermatic artery; P, Anterior crural nerve; Q, Ilio-inguinal nerve; R, Genitocrural 
nerve; S, External cutaneous nerve; T, Iliac fascia; M, Lumbar artery and iliohypogastric (or 
dorsal) nerve. 



up toward the eleventh rib as necessary — the incision of the two latter muscles 
corresponding in direction with the separation of the fibers of the external 
oblique (Fig. 40). In this higher part of the wound the last dorsal and 
other dorsal nerves are apt to be encountered between the internal oblique 
and transversalis, and are to be carefully preserved. The deep circumflex 
iliac artery and the lumbar arteries are apt to be met here above the crest 
of the ilium. Having divided the transversalis fascia and separated the 
peritoneum from the iliac fascia (which overlies the iliacus muscle), detaching 
it downward and backward to the psoas muscle and then upward to the 



SURGICAL ANATOMY OF INTERNAL ILIAC ARTERY. 83 

sacral promontory, the structures in the floor of the iliac fossa are exposed. 
The external iliac artery is first found, and this is followed up to the common 
iliac, guarding the deep epigastric. The genitocrural, external cutaneous, 
and anterior crural nerves, branch of the iliolumbar, and the spermatic 
arteries cross this area. The ureter crosses either the common iliac, or the 
external iliac, obliquely, opposite the first piece of the sacrum, having the 
ileum in front of it on the right, and the sigmoid flexure of the colon in front 
of it on the left; but in the peeling back of the peritoneum the ureter usually 
adheres to the peritoneum, and is thus removed from the area of operation 
without trouble. The artery having been reached and bared of peritoneum, 
the needle is passed from the iliac vein. 

Comment. — The line of incision may begin further to the outer side 
of the external iliac than for the typical operation upon that artery, though 
that vessel is then a little less easily encountered. As to a choice between 
the extraperitoneal and intraperitoneal operations, the former is to be pre- 
ferred wherever the relations of the parts are not too much disturbed by 
disease or injury. 

Collateral Circulation. — Internal mammary and lower intercostals 
above, with deep epigastric below. Lumbar above, with deep circumflex 
iliac and iliolumbar below. Superior hemorrhoidal above, with middle and 
inferior hemorrhoidal below. Aliddle sacral above, with lateral sacral below. 
Pudic, epigastric, obturator and epigastric branches of one side, with corre- 
sponding arteries of other side. 



LIGATION OF COMMON ILIAC ARTERY 

BY TRANSPERITONEAL OPERATION. 

Position — Landmarks — Incision — Operation. — The steps are prac- 
tically the same as for the transperitoneal ligation of the abdominal aorta, 
though somewhat less extensive, and with the slight modifications necessitated 
by the anatomy of the parts (Fig. 39, C). Especial care is taken to recognize 
the position of the ureter before incising the peritoneum. 



SURGICAL ANATOMY OF INTERNAL ILIAC ARTERY. 

Description. — About 4 cm. (1^ inches) in length — arising from bifurca- 
tion of common iliac, opposite upper border of sacro iliac synchondrosis. 
Descends in pelvis to upper margin of great sacrosciatic foramen, where it 
divides into anterior and posterior branches. 

Relations. — Anteriorly: peritoneum; ureter. Posteriorly: termina- 
tion of external iliac vein; internal iliac vein; inner border of psoas; lumbo- 
sacral cord; obturator nerve; sacrum. Externally: psoas. Internally: 
internal iliac vein; peritoneum. 

Branches. — From Anterior Trunk: — Hypogastric; superior, middle, and 
inferior vesical; middle hemorrhoidal; obturator; sciatic; internal pudic; 
uterine; vaginal. From Posterior Trunk: — Iliolumbar; lateral sacral; glu- 
teal. 

Line of Artery. — See under Line of Common Iliac. 

Indications for Ligation. — Gluteal and sciatic aneurism; hemorrhage; 
to cause atrophy of prostate gland. 

Sites for Ligation. — Midway between its origin and its bifurcation. 



84 OPERATIONS UPON THE ARTERIES. 

LIGATION OF INTERNAL ILIAC ARTERY 

BY RETROPERITONEAL OPERATION. 

Position — Landmarks — Incision — Operation. — Same as for the retro- 
peritoneal ligation of the external iliac— which, having been exposed, is 
followed up to the bifurcation of the common iliac (Fig. 39, B, and Fig. 

44)- 

Collateral Circulation. — Sciatic above, with superior branch of profunda 
below. Inferior mesenteric above, with hemorrhoidal arteries below. Pubic 
branch of obturator of one side, with same of opposite. Branches of pudic 
of one side, with same of opposite. Circumflex and perforating of profunda 
above, with sciatic and gluteal below. Middle sacral above, with lateral 
sacral below. Circumflex iliac above, with iliolumbar and gluteal below. 



LIGATION OF INTERNAL ILIAC ARTERY 

BY TRANSPERITONEAL OPERATION. 

Position— Landmarks— Incision— Operation. Same as for the trans- 
peritoneal ligation of the abdominal aorta, with the modifications necessitated 
by the anatomy of the parts (Fig. 39, C, and page 80). Recognize the 
position of the ureter before incising the peritoneum. 



SURGICAL ANATOMY OF SCIATIC BRANCH OF ANTERIOR DIVISION 
OF INTERNAL ILIAC. 

Description and Relations. — Larger of two terminal branches of 
anterior trunk. Descends over sacral plexus and pyriformis muscle to lower 
part of great sacrosciatic foramen, whence it passes out of pelvis between 
pyriformis and coccygeus muscles, with pudic artery anterior and internal 
to it. Emerging through great sciatic foramen upon buttock, beneath the 
gluteus maximus, it descends the thigh midway between trochanter major 
and tuberosity of ischium, resting upon gemellus superior, obturator internus, 
gemellus inferior, quadratus femoris and adductor magnus — being to inner 
side of great sciatic nerve and accompanied by small sciatic nerve. 

Line of Artery. — Having rotated the thigh inward and slightly flexed 
it, draw a line from the posterior superior iliac spine to the outer border 
of the tuberosity of the ischium. A point on this line, at the junction of its 
middle and lower thirds, will represent the site at which the sciatic and pudic 
arteries emerge from the lower part of the sciatic foramen upon the gluteal 
region (Fig. 41, A, C, E). 

Indications for Ligation. — Wounds. 

Site for Ligation. — At its emergence onto the gluteal region, just below 
the pyriformis muscle (Fig. 41). 



LIGATION OF SCIATIC BRANCH OF INTERNAL ILIAC 

UPON THE BUTTOCK. 

Position. — Patient upon uninvolved side, rolled nearly onto chest, with 
knee flexed and thigh rotated in. Surgeon on side of operation; assistant 
opposite. 



SURGICAL ANATOMY OF INTERNAL PUDIC ARTERY. 



85 



Landmarks. — Posterior superior iliac spine; tuberosity of ischium. 

Incision. — Having drawn the line given under Anatomy, make an in- 
cision about 10 cm. (4 inches) in length, obliquely across this line, in the 
direction of the fibers of the gluteus maximus (which run from above and 
behind, downward and forward) — with its center corresponding to the junc- 
tion of the middle and lower thirds of the line (Fig. 41, E). 

Operation. — Having incised skin and thick fatty areolar tissue, divide 




9^\ 

y 
m 



, 











Fig. 41. — Incisions for Ligations about the Buttock : — A, Posterior superior iliac spine ; B, 
Great trochanter; C, Tuberosity of ischium; D, Incision for exposure of gluteal branch of internal 
iliac at its emergence from upper part of great sacrosciatic notch ; E, For exposure of sciatic and 
internal pudic branches of internal iliac at their emergence from lower part of great sacrosciatic notch. 

the fibers of the gluteus maximus in their cleavage line (Fig. 42, F). Retract 
the separated margins of this muscle upward and downward, respectively. 
Expose the lower margin of the pyriformis muscle. Follow the lesser sacro- 
sciatic ligament to the spine of the ischium — when the sciatic artery will be 
found emerging from beneath the pyriformis muscle — passing out of the 
pelvis above the spine of the ischium, and the lesser sacrosciatic ligament 
attached to it — and lying posterior and external to the pudic artery. 



SURGICAL ANATOMY OF INTERNAL PUDIC BRANCH OF ANTERIOR 
DIVISION OF INTERNAL ILIAC. 

Description. — Smaller of two terminal branches of anterior trunk of 
internal iliac. Descends over pyriformis and sacral plexus to lower border 
of great sacrosciatic foramen, lying in front and to inner side of sciatic artery — ■ 
passes thence out of pelvis between pyriformis and coccygeus — crosses over 



86 OPERATIONS UPON THE ARTERIES. 

outer surface of spine of ischium, under gluteus . maximus, and re-enters 
pelvis through lesser sciatic notch — passing, thence, forward over obturator 
interims muscle, along outer wall of ischiorectal fossa, about 4 cm. (i£ inches) 
above the lower margin of the tuberosity of ischium, and contained in a canal 
of the obturator fascia. Gradually approaching the border of the ischial 
ramus, it runs forward and upward — pierces posterior layer of deep perineal 
fascia, runs forward along inner margin of ramus of pubis, giving off artery 
of cms penis and artery of bulb between layers of triangular ligament — piercing 
anterior layer of deep perineal fascia as the dorsal arterv of penis. 

Relations. — (a) Within Pelvis: — descends over pyriformis muscle and 
sacral plexus to lower border of great sacrosciatic notch, whence it emerges 
between pyriformis and coccygeus muscles, together with sciatic artery, 
pudic nerve, greater and lesser sciatic nerves, and nerve to obturator internus 




Fig. 42. — Ligation of Right Internal Pudic and Sciatic Arteriks upon the Buttock, be- 
low the Pyriformis: — A, A, Gluteus maximus (incised and retracted); P>, Pyriformis (lower 
border retracted upward); C, Obturator internus, with gemellus superior and inferior, above and 
beli iw ; D, Pudic artery and venae comites ; E, Internal pudic nerve ; F, Sciatic artery and venae com- 
ites ; G, Small sciatic nerve ; H, Great sciatic nerve. 

muscle, (b) Crossing Spine of Ischium: — is covered by gluteus maximus and 
edge of great sacrosciatic ligament. A vena comes is on either side, and the 
nerve to the obturator internus to the outer side and the pudic nerve to the 
inner side, (c) On Obturator Internus Muscle: — bound to muscle by sheath 
of obturator layer of pelvic fascia (Alcock's canal), with dorsal nerve of penis 
above and superficial perineal nerve below, (d) Between Two Layers of 
Triangular Ligament: — runs near to ramus of pubis, in substance of com- 
pressor urethra? muscle. 

Line of Artery. — See Surgical Anatomy of Sciatic Artery. 

Indications for Ligation. — Wounds. 

Sites for Ligation. — Over the spine of the ischium, or in the perineum. 
(Fig 41, E.) 

Comment. — The main trunk of the arterv is the same in both sexes. 



LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY. 87 
LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC 

UPOX THE BUTTOCK. 

Position — Landmarks — Incision — Operation. — Same as for Ligation 
of Sciatic Branch of Internal Iliac upon the Buttock — the arteries lying side 
by side at their exit from the pelvis, below the lower border of the pyriformis 
(Fig. 41, E, and Fig. 42, D). 

LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC 

IN THE PERINEUM. 

Position. — Patient in lithotomy position. Surgeon sits facing buttock. 

Landmarks. — Tuberosity and ascending ramus of ischium. 

Incision. — Begins about 7.5 cm. (3 inches) above inner border of tuber- 
osity of ischium and passes downward along the margin of the ascending 
ramus of the ischium. 

Operation. — Divide skin and fascia, avoiding inferior pudendal nerve 
beneath the superficial fascia. The erector penis muscle is exposed (in the 
male). The transversus perinan is either cut or drawn downward and in- 
ward. Divide the base of the triangular ligament and adjacent parietal 
pelvic fascia — when the artery will be found running forward above the 
pudic nerve, upon the inner surface of the obturator internus muscle, and 
above the attachment of the great sacrosciatic ligament. 



SURGICAL ANATOMY OF GLUTEAL BRANCH OF POSTERIOR DIVI- 
SION OF INTERNAL ILIAC. 

Description and Relations. — Largest branch of posterior division, of 
which it is the continuation. Passes backward and downward between 
first sacral nerve and lumbosacral cord — leaving pelvis through upper part 
of sacrosciatic notch, above pyriformis, in osseotendinous groove formed by 
margin of bone and pelvic fascia, accompanied by gluteal vein and superior 
gluteal nerve, — emerging from the pelvis under the gluteus maximus, where 
it divides into its branches just above the upper border of the pyriformis 
muscle. 

Line of Artery. — Having rotated inward and slightly flexed the thigh, 
draw a line from the posterior superior iliac spine to the top of the great 
trochanter. A point on this line at the junction of the upper and middle 
thirds will correspond with the emergence of the gluteal artery from the 
sciatic notch (Fig. 41, A, B, D). 

Indications for Ligation. — Wounds; aneurism. 

Site for Ligation. — At emergence from sciatic notch, at upper border 
of pyriformis muscle (Fig. 41). 



LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY 

ON THE BUTTOCK. 

Position. — Patient on involved side, rolled nearly onto chest; knee flexed; 
thigh rotated inward. Surgeon on side of operation. 

Landmarks. — Posterior superior iliac spine; top of great trochanter. 



88 OPERATIONS UPON THE ARTERIES. 

Incision. — Having drawn the line given under Surgical Anatomy, an 
incision about to cm. (4 inches) in length is drawn along this line, with its 
center corresponding with the junction of its upper and middle thirds, which 
will be over the site at which the gluteal artery leaves the sciatic notch 
(Fig. 41, D). 

Operation. — After dividing skin, superficial fascia, some superficial 
nerves, and the fascia of the gluteus maximus, the muscle itself is met, its 
fibers running parallel with the skin incision (Fig. 43). Incise the muscle- 
fibers of the gluteus maximus along their cleavage line. Having passed 
through the thickness of the gluteus maximus, a branch of the gluteal artery 
will generally lead to the interval between the gluteus medius and pyriformis 
(which otherwise is sought without this guide). Having divided the fascia 
over the lower border of the gluteus medius, separate these muscles by re- 
tractors and expose the upper margin of the sciatic notch by passing the 




Fig. 43.— Ligation of Right Gluteal Artery upon the Buttock, above the Pyriformis: — 
A, Deep fascia over gluteus maximus; B, B, Gluteus maximus, incised and retracted; C, Gluteus 
medius (retracted upward) ; D, Pyriformis (retracted downward i ; E, Fascia between gluteus max- 
imus and gluteus medius and pyriformis; F, Gluteal artery and vena; comites ; G, Superior gluteal 
nerve and branches; H, Gluteus minimus. 



finger under the lower border of the gluteus medius — and through the upper 
portion of the sciatic notch, between the lower border of the gluteus medius 
and upper border of the pyriformis, emerge the gluteal artery, vein, and 
superior gluteal nerve. 



SURGICAL ANATOMY OF EXTERNAL ILIAC ARTERY. 

Description. — The larger (in the adult) branch of common iliac. About 
9 to 10 cm. (3^ to 4 inches) in length. Arises at bifurcation of common 
iliac at sacro-iliac synchondrosis — running thence obliquely downward and 
outward along brim of pelvis, upon inner border of psoas muscle — passing 
under lower border of Poupart's ligament, midway between anterior superior 
iliac spine and symphysis pubis, to become femoral. The external iliac vein 
lies to inner side of artery below, and to inner and posterior aspect above. 



LIGATION OF EXTERNAL ILIAC. 89 

The deep epigastric artery arises about 6 mm. (\ inch) above Poupart's 
ligament, and runs between transversalis fascia and peritoneum toward the 
umbilicus. The deep circumflex iliac arises below the deep epigastric, and 
passes behind Poupart's ligament upon the iliacus muscle. The internal 
abdominal ring is situated about 1.3 cm. (% inch) above Poupart's ligament, 
and midway between anterior superior iliac spine and spine of os pubis, 
and hence just external to course of artery. 

Relations. — Anteriorly: Parietal peritoneum; subperitoneal fascia; end 
of ileum, on right; sigmoid flexure of colon, on left; genital branch of genito- 
crural nerve (over its lower third); circumflex iliac vein; spermatic artery 
and vein; ovarian vessels (in female); vas deferens; ureter (sometimes); ex- 
ternal iliac lymphatic vessels and glands. Posteriorly : External iliac vein ; 
inner border of psoas magnus and its tendon; iliac fascia. Internally: 
External iliac vein; peritoneum; vas deferens; ovarian vessels, in female. 
Externally: Psoas magnus; iliac fascia. 

Branches. — Deep epigastric; deep circumflex iliac; several branches to 
psoas magnus and lymphatic glands. 

Line of Artery. — See Surgical Anatomy of Common Iliac. 

Indications for Ligation. — Wounds; secondary hemorrhage; femoral 
or iliofemoral aneurisms; to arrest malignant growths; in elephantiasis arabum; 
as a distal ligation in aneurism of common iliac. 

Sites of Ligation. — Proximal to deep epigastric and deep circumflex iliac 
branches (Fig. 39, D). 



LIGATION OF EXTERNAL ILIAC 

BY RETROPERITONEAL ROUTE. 

Position. — Patient supine, near edge of table. Surgeon on side of 
operation.' 

Landmarks. — Poupart's ligament; anterior superior iliac spine; line of 
artery. 

Incision. — Begins over external iliac artery, about 1.3 cm. (h inch) 
above Poupart's ligament, and passes upward and outward parallel with 
the ligament, to the anterior superior iliac spine — and is prolonged upward as 
far as necessary, in the cleavage line of the external oblique (Fig. 39, D). 

Operation. — (1) Having incised skin, superficial fascia — together with, 
possibly, the superficial epigastric, branches of superficial circumflex iliac, 
with their veins, ligating where necessary, expose the aponeurosis of the 
external oblique (Fig. 44). (2) Divide this aponeurosis in its cleavage line, 
without cutting its fibers — and continue this division, or separation, in the 
cleavage line as far toward or beyond the anterior superior iliac spine as 
indicated to give free room for manipulation. (3) Having retracted the cut 
edges of the external oblique well apart, separate from the outer half of 
Poupart's ligament the attachment of the internal oblique. Carefully retract 
the cut edges of the internal oblique, being on the watch for branches of the 
iliohvpogastric and ilio-inguinal nerves between the internal oblique and 
transversalis, and, if encountered, carefully displace them above or below, 
but avoid cutting them. If necessary to gain more room, the internal oblique 
is to be incised in the line of the separation of the external oblique as far as 
the upper limit of the separation of the fibers of the latter muscle. (4) Having 
incised the internal oblique and protected the nerves encountered, detach 
the transversalis from the outer third of Poupart's ligament, and as far beyond 



9° 



OPERATIONS UPON THE ARTERIES. 



as necessary, incising its fibers transversely to their direction, but in the 
direction of the division of the internal oblique. After dividing the trans- 
versalis, guard the deep circumflex iliac artery and vein and the genitocrural 
nerve, both lying between the transversalis fascia and peritoneum. (5) 
Having now separated the fibers of the aponeurosis of the external oblique, 
and divided the fibers of the internal oblique and transversalis in the same 
line as the separation of the external oblique aponeurosis, and having safe- 
guarded the important nerves encountered, the fascia transversalis is then 
exposed and is divided over the artery in a transverse direction, corresponding 




Fig. 44— Ligation of Right External Iliac, Retroperitoneally— through Oblique In- 
cision Parallel with Poupart's Ligament: — A, A, Superficial epigastric artery; B, External 
oblique muscle ; C, C, G, External oblique aponeurosis ; D, Internal oblique; E, Ilioinguinal nerve ; 
F, Transversalis muscle; H, Deep circumflex iliac artery and accompanying vein; I, Deep epigas- 
tric artery and venae comites ; J, Genitocrural nerve ; K, Peritoneum (peeled back and retracted up- 
ward) ; L, Iliac fascia ; M, External iliac artery (its sheath incisedj ; N, External iliac vein ; O, An- 
terior crural nerve (seen through fascial ; P, Poupart's ligament. 



with the preceding separation and incision lines. The artery is here clearly 
defined, and the deep epigastric, the main source of collateral circulation, 
is carefully guarded. (6) As soon as the artery is clearly located, the sub- 
peritoneal tissue about the vessel is carefully opened up and the artery well 
exposed — as well as the deep epigastric, for the purpose of guarding it. The 
peritoneum is then pushed and rolled backward and upward from the vessel 
with the fingers and held out of the way by retractors. (7) When sufficiently 
exposed, the sheath of the artery is opened and the needle passed from the 
vein on its inner side guarding the anterior crural nerve on its outer side. 
The ligature should be about 3 cm. (i\ inches) above Poupart's ligament. 
(8) In concluding the operation, the cut edges of the transversalis are united 
by buried catgut sutures to their line of severance from Poupart's ligament, 
and as far beyond as they may have been divided. The cut edges of the 
internal oblique are similarly sutured to their former attachment to Poupart's 
ligament, and to their opposite cut margin as far beyond as divided. And, 



SURGICAL ANATOMY OF FEMORAL ARTERY. QI 

finally, the separated margins of the external oblique are united by a buried 
gut suture. The skin wound is then closed. 

Comment. — The incision for exposure may, if thought necessary, begin 
about 3 cm. (i| inches) to the outer side of the spine of the os pubis — being 
thus begun well to the inner side of the artery, as in the modified Astley 
Cooper operation. 

Collateral Circulation. — Internal mammary, lumbar, lower intercostals, 
above; with deep epigastric, below. Iliolumbar, lumbar, gluteal, above; 
with deep circumflex iliac, below. Obturator and sciatic, above; with internal 
circumflex below. Sciatic, above; with superior perforating, below. Gluteal, 
above; with external and internal circumflex and first perforating, below. 
Internal pudic, above; with external pudic, below. 



LIGATION OF EXTERNAL ILIAC 

BV TRANSPERITONEAL ROUTE. 

Position. — As in the extraperitoneal operation. Or in the Trendelen- 
burg position. 

Landmarks. — As for the extraperitoneal exposure. 

Incision. — The incision may be in one of three sites: (a) As an intra- 
muscular incision, placed over the site of the artery to be tied (Fig. 39, F); 
(b) vertical, in the linea semilunaris (Fig. 39, E); or (c) vertical, in the linea 
alba (Fig 39 , C). 

Operation. — The steps of the operation and the manipulation to expose 
the site of ligation are, practically, similar to those in the transperitoneal 
exposure of the common iliac, or the internal iliac. 



SURGICAL ANATOMY OF FEMORAL ARTERY. 

Description. — Continuation of external iliac. Begins at lower border 
of Poupart's ligament, midway between anterior superior iliac spine and 
symphysis pubis — passes down anterior and inner side of thigh to opening 
in adductor magnus, at junction of middle and lower thirds of thigh, through 
which it passes into popliteal space, becoming popliteal artery. Above, the 
artery lies near the antero-internal aspect of head of femur. Below, it is 
close to inner side of bone. Between, it is some distance from bone. In 
its upper third the artery passes from the center of base to apex of Scarpa's 
triangle. [Scarpa's triangle is bounded, externally, by sartorius; internally, 
by adductor iongus; its base, above, being formed by Poupart's ligament; 
its apex, below, at junction of sartorius and adductor Iongus. Its floor 
(from without inward) is formed by iliacus, psoas, pectineus, small part of 
adductor brevis, and small part of adductor Iongus. It contains femoral 
artery (in its center), with its cutaneous and profunda branches; femoral vein 
(toward inner side), with deep femoral vein and internal saphenous branches, 
passing from middle of base to apex; anterior crural nerve (to outer side): 
lymphatic glands.] In its lower third the artery passes through Hunter's 
canal. [Hunter's canal is an aponeurotic canal extending from apex of 
Scarpa's triangle to femoral opening in adductor magnus, and formed, ex- 
ternally, by vastus internus; postero-internaily, by adductor Iongus and 
magnus; antero-internally, by aponeurosis stretching from vastus internus 
over femoral vessels to adductor Iongus and magnus, the sartorius passing 
over top of this aponeurosis. It contains femoral artery, femoral vein (each 



92 



OPERATIONS UPON THE ARTERIES. 



in its own sheath, the vein being behind and external to artery), and long 
saphenous nerve (external to vessels).] 

Divisions of Artery.— Common Femoral— first 4 cm. (i 1 inches). 
Superficial Femoral— made up by remainder (about 9 cm.— 3$ inches). Deep 
Femoral — profunda femoris branch. 

Relations.— (a) Common Femoral :— Anteriorly— skin; superficial 
fascia; superficial inguinal glands; iliac portion of fascia lata; continuation 
of transversalis fascia into femoral sheath; crural branch of genitocrural 
nerve; superficial circumflex iliac vein; superficial epigastric vein (sometimes). 
Posteriorly — continuation of iliac fascia into femoral sheath; pubic portion 
of fascia lata; nerve to pectineus; psoas muscle; pectineus muscle; capsule 
of hip-joint. Externally— anterior crural nerves. Internally— femoral 
vein, (b) Superficial Femoral Artery in Scarpa's Triangle :— Anteriorly 
—skin; superficial fascia; crural branch of genitocrural nerve; deep fascia; 




Fig. 45. —Incisions for Ligation of Chief Arteries of Thigh :— A. Anterior superior iliac 
spine ; B, Symphysis pubis ; C, Adductor tubercle ; D, Mid-point between anterior superior iliac spine 
and symphysis pubis ; E, Ligation of common femoral at baseof Scarpa's triangle, by incision parallel 
with artery; F, Same, by incision parallel with and just below Poupart's ligament; G, Of profunda 
femoris, near origin ; H, Of superficial femoral at apex of Scarpa's triangle ; I, Of superficial femoral 
in Hunter's canal ; J, Of popliteal in upper part of popliteal space, from inner side of thigh. 



internal cutaneous nerve. Posteriorly — femoral vein; profunda vein; pro- 
funda artery; pectineus muscle; adductor longus. Externally — long saphe- 
nous nerve; nerve to vastus internus. Internally — femoral vein (getting 
behind artery at apex of Scarpa's triangle), (c) Superficial Femoral 
Artery in Hunter's Canal: — Anteriorly — skin; superficial fascia; deep 
fascia; sartorius; aponeurotic roof of Hunter's canal; internal saphenous 
nerve. Posteriorly — angle of junction of vastus internus and adductors; 
femoral vein (lying, in middle of Hunter's canal, behind and becoming 
slightly external and closely adherent to artery). Externally— vastus internus, 
femoral vein (at lower part of Hunter's canal). Internally— adductor longus 
(above) ; adductor magnus (below) . 

Branches. — From Common Femoral — superficial epigastric, superficial 
circumflex iliac, superficial external pudic, deep external pudic, profunda. 
From Superficial Femoral in Scarpa's Triangle— muscular, saphenous. 



LIGATION OF COMMON FEMORAL. 93 

From Superficial Femoral in Hunter's Canal— muscular, anastomotica 
magna. 

Line of Artery. — (With hip slightly flexed, thigh abducted and rotated 
outward.) From a point midway between anterior superior iliac spine 
and symphysis pubis, to adductor tubercle of internal femoral condyle 
(Fig. 45, D, C). (When thigh in normal position and parallel with its 
fellow — from midway between anterior superior iliac spine and symphysis 
pubis, to inner border of patella.) 

Sites for Ligation. — Common femoral at base of Scarpa's triangle — 
rare (on account of proximity of large vessels). Superficial femoral at apex 
of Scarpa's triangle — operation of election. Superficial femoral in Hunter's 
canal — not common (Fig. 45). 

Indications for Ligation.— As for ligation of External Iliac (page 89). 

Comment. — (i) A short common femoral is more frequent than a long 
one. (2) Apex of Scarpa's triangle is from 7.5 to 9 cm. (3 to 3$ inches) 
below Poupart's ligament. (3) Profunda femoris arises about 4 cm. (i£ 
inches) below Poupart's ligament. (4) At groin, femoral artery and vein 
are on same plane — at apex of Scarpa's triangle, vein is posterior — in middle 
of Hunter's canal, vein is posterior and slightly external — at lower part of 
Hunter's canal, vein is external. (5) Order of vessels at apex of Scarpa's 
triangle, from before backward, is femoral artery, femoral vein, profunda 
vein, profunda artery. (6) Line approximately representing course of long 
saphenous vein is one running from a point about 2 cm. (f inch) internal to 
mid-point between anterior superior iliac spine and symphysis pubis, to 
posterior border of sartorius muscle at femoral condyle. 

LIGATION OF COMMON FEMORAL 

AT BASE OF SCARPA'S TRIANGLE— BY INCISION PARALLEL WITH ARTERY. 

Position. — Patient supine; hip slightly flexed; thigh abducted and rotated 
outward; knee bent and lying upon its outer aspect. Surgeon stands on 
side of operated limb, cutting from above downward on the right, and vice 
versa. 

Landmarks. — Line of artery (page 93) . 

Incision. — About 5 cm. (2 inches), beginning just a little above Poupart's 
ligament and extending downward in line of artery (Fig. 45, E). 

Operation. — Incise skin and superficial fascia. Avoid lymphatic glands 
— also the superficial circumflex iliac, superficial epigastric, and superficial 
external pudic arteries and veins. Divide the iliac portion of the fascia lata 
(Fig. 46). Avoid the crural branch of the genitocrural nerve on the femoral 
sheath, a little external to the artery. Expose and open the sheath, guarding 
the femoral vein, which lies immediately to the inner side of the artery and 
within the sheath — and the anterior crural nerve lying further to the outer 
side of the artery and outside of the sheath. Pass the needle from the vein 

(Fig. 47)- 

Comment. — (I) Ligation at the base of Scarpa's triangle is rarely done, 
owing to the nearness and number of the branches — except in such cases 
as wounds, and to control hemorrhage at the hip-joint, or for temporary 
control in operating about the thigh. Where not otherwise indicated, ligation 
of the external iliac is the better operation. (2) The artery may also be 
exposed, at this site, by an incision parallel with and about 6 mm. (^ inch) 
below the middle third of Poupart's ligament (Fig. 45, F). 

Collateral Circulation. — Internal pudic of internal iliac; with pudic 



94 



OPERATIONS UPON THE ARTERIES. 



of femoral. Gluteal; with external and internal circumflex and superior 
perforating. Superficial circumflex iliac; with external circumflex. Ob- 
turator; with internal circumflex. Sciatic; with superior perforating and 




Fig. 46. — Ligation of Right Common Femoral at Base of Scarpa's Triangle: — A, A> 
Superficial fascia; B, B, Fascia lata; D, Pectineus; E, Psoas; G, G, Poupart's ligament and external 
oblique; H, Common femoral artery, with superficial epigastric, external pudic, and circumflex 
iliac branches; I, I, Femoral vein; J, Internal saphenous, with superficial epigastric, external 
pudic, and circumflex iliac veins; K, Anterior crural nerve; L, Crural branch of genitocrural. 

internal circumflex. Comes nervi ischiadici; with all the perforating branches 
of profunda and articular of popliteal. 



SURGICAL ANATOMY OF PROFUNDA FEMORIS BRANCH OF COMMON 

FEMORAL ARTERY. 

Description. — Largest branch of femoral, nearly equaling main trunk. 
Arises from externo-posterior aspect of common femoral, about 4 cm. (ih 
inches) below Poupart's ligament — passing down thigh, at first external to 



LIGATION OF PROFUNDA FEMORIS. 



95 



superficial femoral — thence posterior to femoral artery and vein to inner 
side of femur — thence leaves femur and runs beneath adductor longus and 
adductor magnus. 

Relations. — Anteriorly: (near origin) skin; superficial fascia; deep 
fascia; branches of anterior crural nerve; (lower down) femoral vein; pro- 
funda vein; (still lower) adductor longus. Posteriorly: (in order) iliacus; 
pectineus; adductor brevis; adductor magnus. Externally : vastus internus. 
Internally: pectineus; angle of junction of adductor brevis and adductor 
magnus. 

Branches. — External circumflex; internal circumflex; three perforating. 

Site of Ligation. — At origin. 

Indications for Ligation. — Wounds of itself and branches. Aneurisms. 






Fig. 47. — Cross-section of the Left Thigh, through the Head of the Femur (The 
skin relations of this section erroneously represent a lower level.): — A, Iliacus; B, Sartorius; 
C, Femoral artery, vein, and crural nerve; D, Pectineus; E, Psoas; F, Tensor vaginas femoris; 
G, Gluteus minimus; H, Gluteus medius; I, Great sciatic artery, vein, and nerve; J, Gluteus 
maximus; K, Obturator internus; L, Obturator externus; M, Adductor brevis; N, Adductor 
longus. (The cross-section from Braune.j 



LIGATION OF PROFUNDA FEMORIS 

NEAR ORIGIN. 

Position. — Patient supine; limb extended and parallel with fellow. 
Surgeon on outer side of operated limb, cutting from above downward on 
the right, and vice versa. 

Landmarks. — Line of artery (with extended limb — see page 93) ; Pou- 
part's ligament. 



9 6 



OPERATION'S UPON THE ARTERIES. 



Incision. — About 5 or 6 cm. (2 or 2^ inches) in length, in line of artery 
— calculating to fall over its outer border, with the center of incision over a 
point in the course of the artery about 4 cm. (ij inches) below Poupart's 
ligament (Fig. 45, G). 

Operation. — Incise skin, superficial fascia, and fascia lata. Expose the 
inner edge of the sartorius and retract it outward. Beneath this muscle 
lies the rectus, with branches of the anterior crural nerve in close relation — 
these are to be drawn outward. The trunk of the common femoral will 
then be exposed, with the profunda coming off from its postero-external 
aspect, and running outward and downward, with the external circumflex 
arising from it and passing under the rectus. The artery is then freed and 
the ligature passed. 




Fig. 48. —Ligation of Right Femoral at Apex of Scarpa's Triangle :— A, Sartorius; B, 
Adductor longus ; C, Femoral artery and muscular branches, with its sheath incised and retracted; 
D, Femoral vein ; E, Branch of internal saphenous vein ; F, Long saphenous nerve ; G, Internal cuta- 
neous nerve. 



LIGATION OF SUPERFICIAL FEMORAL 

AT APEX OF SCARPA'S TRIANGLE. 

Position. — Same as for ligation of common femoral at base of Scarpa's 
triangle. 

Landmarks. — Line of artery. 

Incision. — About 7.5 cm. (3 inches) in length, in line of artery — with its 



LIGATION OF SUPERFICIAL FEMORAL ARTERY. 



97 



center over apex of Scarpa's triangle, that is, about 7.5 cm. (3 inches) below 
Poupart's ligament (Fig. 45, H). 

Operation. — Incise skin and superficial fascia. Draw aside, or ligate, 
branches of internal saphenous vein (Fig. 48). Divide fascia lata. Identify 
inner margin of sartorius (fibers running downward and inward) and retract 
outward. Open up the groove between the sartorius and adductor longus 
(fibers of latter running directly downward, or downward and outward) and 
retract the adductor longus internally, if necessary. The internal cutaneous 
nerve and long saphenous nerve are encountered anterior to the artery, and 
are to be displaced to one side. Clearly identify the femoral sheath and 
incise — guarding the femoral vein, which lies posteriorly and internally to 
the artery. Pass the needle from the vein. 

Collateral Circulation. — External circumflex; with lower muscular 
branches of femoral, anastomotica magna, superior articular of popliteal, 
and anterior tibial recurrent. Perforating and terminating of profunda, 
with muscular branches of femoral and muscular and superior articular 
branches of popliteal. Comes nervi ischiadici; with perforating of profunda 
and articular of popliteal. 




Fig 49. — Ligation of the Right Femoral Artery in Hunter's Canal: — A, Internal 
cutaneous nerve; B, Sartorius; C, Hunter's canal, the roof incised; D, Femoral artery; E, Femoral 
vein: F, Internal saphenous nerve. 
7 



9 8 



OPERATIONS UPON THE ARTERIES. 




Fitr. 50. — Cross-section through the Middle of the Left Thigh: — A Rectus muscle; 
B, Vastus interims; C, Sartorius; D, Superficial femoral artery, vein, and saphenous nerve; 
E, Adductor longus; F, Adductor magnus; G, Gracilis; H, Semimembranosus; I, Vastus externus; 
J, Descending branch of external circumflex; K, Terminal branch of profunda femoris; L, 
Crureus; M, Great sciatic nerve and arteria comes nervi ischiadici; N, Biceps; O, Semitendinosus. 
(The cross section modified from Braune.) 



LIGATION OF SUPERFICIAL FEMORAL 

IN HUNTER'S CANAL. 

Position. — Same as for common femoral at base of triangle. 

Landmarks. — Line of artery. 

Incision. — From 7.5 to 9 cm. (3 to 3^ inches), in line of artery — over 
middle third of thigh (Fig. 45, I). 

Operation. — Incise skin and superficial fascia. The anterior branch of 
the internal cutaneous nerve, to the outer side, and the long saphenous vein, 
to the inner side, are likely to be encountered. Divide the fascia lata. Ex- 
pose the outer edge of the sartorius (its fibers running downward and inward) 
and retract inward from its position over the roof of Hunter's canal. Hunter's 
canal is thereby exposed in the interval between the vastus internus and the 
adductor magnus (the fibers of the latter running obliquely downward and 
outward). The nerve to the vastus internus may be here exposed. Incise 
the roof of the canal, when the internal saphenous nerve is found between 
the aponeurotic roof and the sheath of the vessels, running from without 
inward. Open the sheath and pass the needle from the vein (Fig. 50). 



SURGICAL ANATOMY OF POPLITEAL ARTERY. 



99 



Comment. — Guard against taking 
the vastus internus for the sartorius — 
the fibers of the former running down- 
ward and outward. 

Collateral Circulation. — Same as 
for the superficial femoral at the apex of 
Scarpa's triangle. 



SURGICAL ANATOMY OF POPLITEAL 
ARTERY. 

Description. — Continuation of fem- 
oral. Extends from aponeurotic open- 
ing in adductor magnus, at junction of 
middle and lower thirds of thigh, down- 
ward and outward through the popliteal 
space to its center behind the knee-joint 
— thence vertically downward to the in- 
ferior border of the popliteus muscle, op- 
posite the lower border of the tubercle of 
the tibia, where it divides into anterior 
and posterior tibial arteries. 

Relations. — Anteriorly : (from above 
downward) popliteal surface of femur; 
posterior ligament of knee; posterior 
articular surface of tibia; popliteus mus- 
cle. Posteriorly : (above) semimem- 
branosus; (center) skin, superficial fascia, 
deep fascia; (below) internal head of gas- 
trocnemius, aponeurotic arch of soleus. 
Popliteal vein lies behind artery through- 
out its course, crossing obliquely from 
outer to inner side, and may be double 
below. Internal popliteal nerve lies be- 
hind artery and vein (immediately pos- 
terior to latter), crossing the vessels ob- 
liquely at their center, from outer to 
inner side. Externally : (above) ex- 
ternal condyle, biceps, internal popliteal 
nerve; (below) outer head of gastroc- 
nemius, plantaris. Internally : (above) 
semimembranosus; (below) inner head 
of gastrocnemius, internal popliteal nerve. 

Branches. — Cutaneous; muscular 
(superior muscular, inferior muscular or 
sural) ; articular (superior external artic- 
ular, superior internal articular, inferior 
external articular, inferior internal artic- 
ular, azygos articular); terminal (poste- 
rior tibial, anterior tibial). 




Fig. 51. — Ligation of Popliteal, 
Posterior Tibial, and Peroneal Ar- 
teries: — A, Outer border of semimem- 
branosus (at junction of middle and lower 
thirds of thigh) ; B, Middle of popliteal 
space ; C, Center of posterior aspect of leg 
on level with tibial tubercle; D, Point 
midway between convexity of heel and tip 
of internal malleolus; E, Mid-point between 
outer border of tendo Achillis and tip of 
external malleolus ; F, Incision for popliteal 

artery in upper part of popliteal space, from behind; G, Same, in lower part of popliteal space; 

H, Of posterior tibial in its upper third ; I, Same, in its middle third; J, Same, in its lower third ; 

K, Same, behind internal malleolus ; L, Incision for peroneal in middle of leg. 



IOO OPERATIONS UPON THE ARTERIES. 

Line of Artery. — From outer border of semimembranosus (at junction 
of middle and lower thirds of thigh) obliquely down to middle of popliteal 
space, directly posterior to the knee-joint (for upper part of artery); and 
from mid-point of popliteal space vertically down to level of lower border 
of tubercle of tibia (for lower part of artery). (Fig. 51, A, B, C.) 

Sites of Ligation. — May be ligated either in its upper part or lower 
part — the artery being tied with difficulty in its middle, owing to its depth 
and relations (Figs. 45, J, and 51, F and G). 

Indications for Ligation. — Rare, other than wounds and aneurism — 
the superficial femoral usually being ligated instead. 

LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL 

SPACE 

FROM BEHIND. 

Position. — Patient as nearly prone as feasible, resting on side of shoulder 
and chest, with limb extended. Surgeon to outer side of left limb, cutting 
downward; and to outer side of right limb, cutting upward (or inside of 
right limb, cutting downward). 

Landmarks. — Line of artery and upper boundaries of popliteal space. 

Incision. — About 9 cm. (3^ inches) in length, in line of artery, beginning 
at outer border of semimembranosus, at junction of middle and lower thirds 
of thigh, and passing obliquely downward to the middle of the popliteal 
space (Fig. 51, F). 

Operation. — Incise skin and superficial fascia. Avoid the small sciatic 
nerve. Open up the deep fascia. Retract the hamstring muscles to the 
outer and inner sides. The popliteal nerve is first encountered crossing from 
the outer to the inner side — the popliteal vein crossing similarly. Displace 
these structures laterally — when the artery is found, generally lying in fatty 
areolar tissue. 

Collateral Circulation. — Where the ligation is between the superior 
and inferior articular arteries; — anastomotic^ magna, superior external and 
internal articular, descending branch of external circumflex, above; with in- 
ferior external and internal articular and anterior tibial recurrent (also, possibly, 
posterior tibial recurrent and superior fibular of anterior recurrent), below. 

Comment. — The upper part of the popliteal artery may also be tied 
from the inner side of the leg (v. i.) — but the above operation is simpler, unless 
the popliteal region be encroached upon by some pathological condition. 

LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL 

SPACE 

FROM INNER SIDE OF THIGH— JOBERT'S OPERATION. 

Position. — Patient supine; thigh slightly flexed; fully abducted and 
rotated outward; knee at a right angle and resting on external aspect. Surgeon 
on outside, cutting downward on right, upward on left (or may stand on 
inner side of left and cut downward) . 

Landmarks. — Tendon of adductor magnus. 

Incision. — About 7.5 cm. (3 inches) in length, beginning opposite the 
junction of middle and lower thirds of thigh, and running parallel with and 
immediately posterior to the tendon of the adductor magnus (which is inserted 
into the adductor tubercle on the internal condyle of the femur). (Fig. 45, J.) 

Operation. — Incise skin and superficial fascia. Avoid anterior branch 
of internal cutaneous nerve (Fig. 52). Divide deep fascia. Expose the 



LIGATION OF POPLITEAL ARTERY. 



IOI 



anterior edge of the sartorius and retract it backward, together with the 
internal saphenous vein, if in view (the internal saphenous nerve being beneath 
the sartorius, out of view). Having thoroughly divided the deep fascia, the 
adductor magnus tendon is identified and drawn forward — then the semi- 




Fig. 52.— Ligation of Upper Part of Right Popliteal from Inner Side of Thigh : — A, 
Anterior branch of internal cutaneous nerve; B, Internal saphenous vein ; C, Sartorius (its anterior 
border retracted posteriorly I ; D, Internal saphenous nerve (mainly under sartorius, out of sight) ; E, 
Adductor magnus (drawn anteriorly); F, Semimembranosus (drawn posteriorly); G, Popliteal 
artery ; H, Popliteal vein (below and external to artery). • 

membranosus is identified and drawn backward — and the artery is then 
sought between these two structures, near the bone and in considerable 
fatty areolar tissue. Both popliteal vein and nerve lie on a plane posterior 
to the artery, and are generally not brought to view. 



LIGATION OF POPLITEAL ARTERY IN LOWER PART OF POPLITEAL 

SPACE 

P.V POSTERIOR MEDIAN INCISION. 

Position. — As for ligation in the upper part of the space. 

Landmarks. — Boundaries of the popliteal space (the biceps above, and 
the plantaris and outer head of gastrocnemius below, forming the outer 
boundary; — and the semimembranosus and semitendinosus above, and the 
inner head of the gastrocnemius below, forming the inner boundary). 



102 OPERATIONS UPON THE ARTERIES. 

Incision. — About 9 cm. (3? inches) in length, beginning at the middle 
of the popliteal space (on a level with the knee-joint) and passing downward 
between the two heads of the gastrocnemius (Fig. 51, G). 

Operation. — Incise skin and superficial fascia. Avoid the external 
saphenous vein and external saphenous nerve in the outer aspect of the 
wound, or the communicans poplitei nerve which helps form the external 
saphenous nerve (Fig. 53). Divide the deep fascia. Expose the inner and 
outer heads of the gastrocnemius, with the sural arteries going to them — 
and retract these and the plantaris muscle to their respective sides. Muscular 
branches of the internal popliteal nerve may be met with here, and maybe 




Fig- 53- — Ligation of Right Popliteal at Lower Part of Popliteal Space: — A, Inner 
head of gastrocnemius (retracted inward l; B, Outer head of gastrocnemius (drawn outward); C, 
Plantaris; D, External saphenous vein ; E, Communicans poplitei nerve; F, Internal popliteal nerve 
(drawn inward) ; G, Popliteal vein (drawn inward] ; H, Popliteal artery and muscular branches; I, 
Popliteus muscle. 



the posterior tibial nerve. The external saphenous vein is the guide to the 
popliteal vessels. The internal popliteal nerve is found most superficial of 
the three important structures — the popliteal vein next (both crossing to the 
inner side, toward which side they are further retracted) — and the artery 
deepest of all, near the bone and in much fatty areolar tissue. The needle 
is passed from the side of the vein, flexure of the knee aiding during this 
stage. 

Comment. — A continuation upward of the above incision would amount 
to ligation of the popliteal artery in the middle of the popliteal space. 



SURGICAL ANATOMY OF ANTERIOR TIBIAL ARTERY 



103 



Collateral Circulation. — If the artery be ligated between the superior 
and inferior articular branches, the 
collateral anastomosis would be the 
same as after the above operation. 



SURGICAL ANATOMY OF ANTERIOR 
TIBIAL ARTERY. 

Description. — The smaller bifur- 
cation of popliteal artery, at lower 
border of popliteus muscle, passing 
thence forward between the two heads 
of tibialis posticus, through aperture 
in upper part of interosseous mem- 
brane, between tibia and fibula, to 
deep part of front of leg — descending, 
at first, on anterior surface of interos- 
seous membrane, then on the tibia, 
and finally onto front of ankle-joint, 
beneath anterior annular ligament, 
where it becomes dorsalis pedis. It 
is accompanied by two vena? comites. 
The anterior tibial nerve accompanies 
its lower three-fourths, lying upon its 
fibular side, though partly overlapping 
it in middle of leg. 

Relations. — Anteriorly : skin, 
superficial fascia; deep fascia; anterior 
tibial nerve (at middle) ; tibialis an- 
ticus (above) ; extensor longus digi- 
torum (above) ; extensor proprius poi- 
nds (below) ; anterior annular ligament 
(below). Posteriorly: interosseous 
membrane (upper two-thirds) ; tibia 
and ankle-joint (lower one-third). Ex- 
ternally : anterior tibial nerve (above 
and below) ; extensor longus digitorum 
(upper third) ; extensor proprius poi- 
nds (middle third). Internally : tibi- 
alis anticus (upper two-thirds) ; ex- 
tensor proprius pollicis (crosses lower 
part of arterv). 

Branches. — Posterior tibial recur- 
rent, superior fibular (sometimes), an- 
terior tibial recurrent, muscular, in- 
ternal malleolar, external malleolar. 

Line of Artery. — From inner side 
of head of fibula, to center of line be- 
tween the malleoli — (according to 
Kocher, from midway between ex- 
ternal surface of head of fibula and 
center of tubercle of tibia, to the 




Fig. 54. — Incisions for Ligation of 
Anterior Tibial and Dorsalis Pedis Ar- 
teries : — A, Incision for upper third of anterii >r 
tibial ; B, For middle third of anterior tibial ; 
C, For lower third of anterior tibial ; D, For 
dorsalis pedis just below ankle-joint; E, For 
dorsalis pedis in first interosseous space; F, 
Inner side of head of fibula ; G, Mid-point be- 
tween two malleoli. 



same point below). The artery passes 



io4 



OPERATIONS UPON THE ARTERIES. 



through the interosseous membrane about 3 cm. (1} inches) below the level 
of the head of the fibula. 

Indications for Ligation.— Wounds (of anterior tibial or in foot); 
aneurism. 

Sites of Ligation.— Upper and middle thirds— rarely, except in wounds. 
Lower third — most frequent site. (Fig. 54). 

LIGATION OF ANTERIOR TIBIAL 

IN ITS UPPER THIRD. 

Position. — Patient supine; leg extended and rotated inward. Surgeon 
on outer side (cutting from above downward, on the right — and vice versa). 

Landmarks. — Line of artery. 

Incision. — About 7.5 cm. (3 inches) in length, in line of artery — beginning 
about 2.5 cm. (1 inch) below head of fibula (Fig. 54, A). 




Fig. 55. — Ligation of the Upper Third of the Right Anterior Tibial Artery: — 
A, Anterior tibial artery; B, Vena; comites; C, Anterior tibial nerve; D, Extensor communis 
digitorum; E, Branch of internal saphenous vein; F, Tibialis anticus muscle. 

Operation. — Incise skin, superficial fascia, and deep fascia. Define the 
gap between tibialis anticus, internally, and extensor longus digitorum, 
externally, and retract these structures to their respective sides (Fig. 55). 
Open up this interval — flexing the foot to relax the parts. Aim to reach the 
external aspect of the tibia, covered by the tibialis anticus, and, when reached, 



LIGATION OF ANTERIOR TIBIAL. 



I°5 



follow down to the interosseous membrane, upon which the artery will be 
found. Two venae comites lie in very close contact, in front of and behind the 
artery. The anterior tibial nerve may not yet have reached the outer side 
of the artery. If the vena; comites be not separable, include them in the 
ligature. 

Comment. — The interval between the tibialis anticus and extensor 
longus digitorum is the key to the situation, and is rather hard to find. The 
outer edge of the tibialis anticus. often overlaps the extensor longus digitorum. 
And also one may get into the septum between the extensor longus digitorum 
and peroneus longus and work down toward the fibula. Guides to the 
proper intermuscular gap, accessory to the sensation of touch, are the " white 
line" (sometimes visible) and a small artery leading to the anterior tibial. 




Fig. 56. — Cross-section through the Upper Third of the Right Leg: — A, Tibialis 
anticus; B, Extensor longus digitorum; C, Anterior tibial vessels and nerve; D, Musculocutaneous 
nerve; E, Peroneus longus; F, F, F, F, Gastrocnemius; H, Posterior tibial vessels and nerve; 
I, Soleus; J, Internal saphenous vein and nerve; K, Popliteus. (The cross-section modified 
from Braune.) 



LIGATION OF ANTERIOR TIBIAL 

IN ITS MIDDLE THIRD. 

Position — Landmarks. — As for ligation of the upper third. 

Incision. — About 7.5 cm. (3 inches) in length, in line of artery, with its 
center over the center of the leg (Fig. 54, B). 

Operation. — Incise skin, superficial and deep fascia. Recognize the 
interval between the tibialis anticus (its outer edge still muscular) internally — 
and the extensor longus digitorum (its inner edge tendinous) externally. A 



io6 



OPERATIONS UPON THE ARTERIES. 



yellow fatty line may sometimes indicate the interval. Open up this interval, 
flexing the foot. Retract these muscles to their own sides — and, deeper in 
the wound, also retract the extensor proprius pollicis to the outer side. Follow 
down the gap toward the tibia (and not the gap between the extensor longus 
digitorum and extensor proprius pollicis). The anterior tibial nerve will be 
found slightly overlapping the artery — draw it outward. The artery will be 
found on the interosseous membrane, under cover of the muscular fibers 
of the tibialis anticus, with the extensor proprius pollicis on its outer side. 
The venae comites are separated with difficulty, and, if so, may be included 
in the ligature. 




Fig. 57. — 'Ligation of Lower Third of Right Anterior Tibial :— A, Tendon of tibialis 
anticus, retracted inward ; B. Extensor proprius hallucis, retracted outward ; C, Extensor longus 
digitorum ; U, Annular ligament ; E, Anterior tibial artery and branches ; F, F, Anterior tibial venae 
comites; G, Anterior tibial nerve; H, Inner branch of musculocutaneous nerve; I, Branch of 
internal saphenous vein. 



LIGATION OF ANTERIOR TIBIAL 

IX ITS LOWER THIRD. 

Position. — As for ligation of the upper third — without the inward rota- 
tion of the foot. 

Landmarks. — Line of artery. 

Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with center over 
center of lower third of leg (Fig. 54, C). 

Operation. — Incise skin and fascia. Clearly identify tendon of tibialis 
anticus. Divide the upper part of the superior band of the anterior annular 
ligament in the line of the wound (Fig. 57). Demonstrate the interval be- 



LIGATION OF DORSALIS PEDIS. 107 

tween the tendon of the tibialis anticus and tendon of the extensor proprius 
pollicis — flexing the foot and retracting these tendons to their own sides. 
The anterior tibial artery will be found between them, lying upon the anterior 
aspect of the tibia and held down by fatty areolar tissue — accompanied by 
two venae comites, and with the anterior tibial nerve on the outer side. Pass 
the needle from the nerve. In closing the wound, suture the anterior annular 
ligament. 

Comment. — If the artery were ligated after passing beneath the obliquely 
crossing extensor proprius pollicis, it would then have the tendon of the 
extensor proprius pollicis to its inner side and the innermost tendon of the 
extensor longus digitorum to its outer side. 

Collateral Circulation. — (When ligated below the malleolar branches.) 
External malleolar of anterior tibial, with anterior peroneal of peroneal and 
with calcaneal of posterior peroneal. Internal malleolar of anterior tibial, 
with internal malleolar of posterior tibial. Dorsalis pedis and branches, 
with internal plantar of posterior tibial, with external plantar of posterior 
tibial, with anterior peroneal of peroneal, and with calcaneal of posterior 
peroneal. Muscular branches of anterior tibial anastomosing through the 
interosseous membrane with muscular branches of posterior tibial. 



SURGICAL ANATOMY OF DORSALIS PEDIS (OF ANTERIOR TIBIAL). 

Description. — Continuation of anterior tibial — extending from bend of 
ankle along tibial side of foot to apex of first intermetatarsal space — passing 
into sole (as communicating artery) between two heads of first dorsal inter- 
osseous. The anterior tibial nerve lies upon its outer side. The artery is 
accompanied by two venae comites. 

Relations. — Anteriorly: Skin, superficial fascia; deep fascia; anterior 
annular ligament; extensor longus pollicis; innermost tendon of extensor 
brevis digitorum. Posteriorly: (from above downward) Astragalus; scaph- 
oid; internal cuneiform; ligament of first and second metacarpals. Ex- 
ternally : Innermost tendon of extensor longus digitorum (above) ; innermost 
tendon of extensor brevis digitorum (below) ; anterior tibial nerve. In- 
ternally : Extensor longus pollicis. 

Branches. — Tarsal; metatarsal; dorsalis hallucis; communicating (plantar 
digital). 

Line of Artery. — From center of line connecting two malleoli, to proximal 
end of first metatarsal space. 

Indications for Ligation. — Rare — wounds, aneurism. 

Sites of Ligation. — At ankle-joint (involves cutting anterior annular 
ligament); below ankle-joint (general site); at first interosseous space (Fig. 
54, D and E). 



LIGATION OF DORSALIS PEDIS 

JUST BELOW ANKLE-JOINT. 

Position. — Patient supine; foot resting on heel and extended. Surgeon 
below foot, on either side, cutting downward (or on outer side of both limbs, 
cutting downward on right, and upward on left). Assistant steadies foot. 

Landmarks. — Line of artery. 



io8 



OPERATIONS UPON THE ARTERIES. 



Incision. — From 2.5 to 5 cm. (1 to 2 in.), in line of artery, passing from 
lower border of anterior annular ligament — between tendon of extensor 
pollicis and inner tendon of extensor longus digitorum (Fig. 54, D). 




Fig. 58. — Ligation of Right Dorsalis Pedis Just below Ankle-joint: — A, A, Branches of 
internal saphenous vein ; B, Internal branch of musculocutaneous nerve and its divisions ; C, Tendon 
of extensor proprius hallucis ; D, Inner tendon of riexor longus digitorum ; E. Inner tendon of exten- 
sor brevis digitorum ; F, Dorsalis pedis artery ; G, Venae comites of dorsalis pedis artery ; H, Ante- 
rior tibial nerve; I, Annular ligament. 

Operation. — Incise skin and superficial fascia. Tributaries of internal 
saphenous vein and the internal branch of the musculocutaneous nerve lie 
in the line of incision (Fig. 58). Open up the deep fascia between the tendon 
of the extensor proprius pollicis and innermost tendon of flexor longus digitorum 
— when the artery will be found upon the tarsal ligaments. The anterior 
tibial nerve lies upon its fibular side — two vena? comites accompanying the 
artery. Avoid opening the tendon sheaths. 

Comment. — When the artery is tied at the base of the first interosseous 
space, an incision is made from the apex of the first interosseous space, passing 
down between the first and second metatarsals. The artery is found emerging 
from under the innermost tendon of the extensor brevis digitorum, which 
is retracted inward. 



SURGICAL ANATOMY OF POSTERIOR TIBIAL ARTERY. 

Description. — Larger and more direct division of popliteal artery — ■ 
extending from lower border of popliteus muscle (on level with lower border 
of tubercle of tibia), down tibial side of back of leg, between superficial and 
deep muscles, to middle of fossa between tip of internal malleolus and os 
calcis — and dividing, under abductor hallucis, into internal and external 



LIGATION OF POSTERIOR TIBIAL. 109 

plantar branches. It arises midway between tibia and fibula, covered by 
the superficial muscles — lower down it lies behind the tibia — and at its lower 
third it is covered by only skin and fascia, and then passes beneath the internal 
annular ligament. It is accompanied by two vena? comites. The posterior 
tibial nerve crosses the artery, from the inner to outer side, about 2.5 to 4 
cm. (1 to 1 J inches) below inferior border of popliteus, and runs thence along 
its fibular aspect. 

Relations. — Anteriorly: (From above downward) tibialis posticus; 
flexor longus digitorum; tibia; internal lateral ligament of ankle-joint. Pos- 
teriorly: Skin; superficial fascia; gastrocnemius; soleus; deep intermuscular 
(transverse) fascia binding artery to underlying muscles; posterior tibial 
nerve (crossing from inner to outer side above, and then running along fibular 
side). In lower third, covered only by skin and fascia. Externally : Poste- 
rior tibial nerve (lower three-fourths) ; vena comes. Internally : Posterior 
tibial nerve (upper one-fourth); vena comes. At Ankle-joint: Posterior 
tibial artery lies under internal annular ligament and abductor hallucis — 
resting upon internal lateral ligament of ankle — having tibialis posticus and 
flexor longus digitorum in front — and posterior tibial nerve and flexor longus 
hallucis behind and externally. 

Branches. — Peroneal, muscular, medullary, cutaneous, communicating, 
internal malleolar, internal calcaneal, external plantar, internal plantar. 

Line of Artery. — Lower half — line from a point 5 cm. (2 inches) below 
center of popliteal space, to midway between tip of internal malleolus and 
center of convexity of heel. Upper half — forms a slight curve inward from 
this line. 

Indications for Ligation. — Wounds; aneurisms. 

Sites of Ligation. — Upper third — not frequent — difficult because of 
depth. Middle third — same. Lower third — most usual site. Behind ankle 
— also common. (Fig. 51, H, I, J, K.) 



LIGATION OF POSTERIOR TIBIAL 

IN ITS UPPER THIRD— ABOVE ORIGIN' OF PERONEAL BRANCH. 

Position. — As for ligation of lower part of popliteal artery (page 101). 

Landmarks. — Popliteal boundaries (page 101); head of fibula. 

Incision. — Begins in popliteal space, on level with head of fibula, and 
passes directly down the middle line for about 7.5 cm. (3 inches) (Fig. 51, H). 

Operation. — Incise skin, superficial fascia, avoiding external saphenous 
vein and nerve. Divide deep fascia, exposing two heads of gastrocnemius. 
Incise their connecting raphe freely and separate them fully, avoiding their 
nerves and vessels as much as possible. Expose the upper border of the 
soleus beneath the external head of the gastrocnemius. Retract the plantaris 
(found between the outer head of the gastrocnemius and soleus). The 
lower border of the popliteus, opposite which the posterior tibial nerve begins, 
about corresponds with the upper border of the soleus — so that after re- 
tracting the internal popliteal nerve and vein to the inner side, draw the 
upper border of the soleus downward (or nick its upper border) and thus 
expose the bifurcation of the popliteal artery into anterior tibial (passing 
through the interosseous membrane) and posterior tibial (descending on 
the deep muscles). Pass the needle between the anterior tibial and peroneal 
branches. 

Collateral Circulation. — (When ligated between the bifurcation and 



no 



OPERATIONS UPON THE ARTERIES. 



origin of the peroneal.) Peroneal of posterior tibial, with communicating 
and muscular branches of the posterior tibial; external calcaneal of peroneal, 
with internal calcaneal of external plantar; external malleolar of anterior 
tibial, with external plantar; internal malleolar of anterior tibial, with internal 
malleolar of posterior tibial; dorsalis pedis and branches, with internal and 
external plantar. 




F'g- 59- — Ligation of Middle Third of Right Posterior Tibial: — A, Internal saphenous 
vein; B, Internal saphenous nerve; C, Soleus, incised vertically, and margins of incision well 
retracted; D, Inner border of gastrocnemius strongly retracted outward ; E, Transverse intermuscu- 
lar fascia ; F, Flexor longus digitorum ; G, Tibialis posticus ; H, Posterior tibial artery ; I, I, Poste- 
rior tibial venae comites ; J, Posterior tibial nerve. 



LIGATION OF POSTERIOR TIBIAL 



IN ITS MIDDLE THIRD. 



Position. — Patient supine; knee flexed; leg on outer side. Surgeon to 
outer side, cutting downward on right, and upward on left. 

Landmarks. — Inner margin of tibia. 

Incision. — From 7.5 cm. to 10 cm. (3 to 4 inches) in length, placed 
parallel with and 2 cm. (f inch) behind the inner margin of the tibia, along 
its middle third (Fig. 51, I). 

Operation. — Incise skin and superficial fascia. Avoid internal saphenous 
vein and internal saphenous nerve (Fig. 59). Divide the deep fascia. The 
inner edge of the gastrocnemius should be identified here — and retracted 
outward. Having gone through the deep fascia, the soleus is exposed, and 
is to be divided along its attachment to the tibia, and its outer part retracted. 



LIGATION OF POSTERIOR TIBIAL. 



The transverse intermuscular fascia (between superficial and deep muscles 
of back of leg) is now in view, and is incised in the axis of the limb, whereby 
the flexor longus digitorum is reached — and, by following along the surface 
of this muscle until nearly opposite the outer border of the tibia, the vena 
comes interna, posterior tibial artery, vena comes externa, and posterior 
tibial nerve are met in order, lying upon the tibialis posticus, or between it 
and the flexor longus digitorum. Pass the needle from the nerve, including 
the vena? comites if unavoidable — flexing the knee and foot to relax the 
structures. (Fig. 60.) 




Fig. 60. — Cross-section of the Middle of the Right Leg: — A, Tibialis amicus; B, 
Extensor longus digitorum; C, Extensor pollicis; D, Anterior tibial artery, vein, and nerve; 
E, Peronei; F, Tibialis posticus; G, Long saphenous vein and nerve; H, Flexor longus digitorum; 
I, Posterior tibial artery, veins, and nerve; J, Soleus; K, Gastrocnemius; L, Peroneal artery 
and veins. (The cross-section modified from Braune.) 

Comment. — The knife should be held at a right angle to the surface 
of the muscle, in cutting through the soleus, pointing toward the tibia until 
the transverse fascia is reached — and thereby wandering too deeply, or in 
the wrong direction, is less likely. If one incise too near the tibia, the flexor 
longus digitorum may be divided and the interosseous membrane reached. 
While incising the soleus, do not mistake its central membranous tendon 
for the transverse intermuscular fascia. The artery lies about 3 cm. (i| 
inches) external to the inner border of the tibia. 



112 OPERATIONS UPON THE ARTERIES. 

LIGATION OF POSTERIOR TIBIAL 

IN ITS LOWER THIRD. 

Position. — As for the middle third. 
Landmarks. — Line of artery. 

Incision. — About 5 cm. (2 inches) in length, in line of artery, with its 
center over the lower third of the leg — which should fall midway between 
the inner border of the tendo Achillis and the inner border of the tibia 
(Fig- 51, re- 
operation. — Incite skin and superficial fascia. Divide the deep fascia 
binding down the flexor tendons — when the artery will be found lying be- 
tween the flexor longus digitorum and flexor longus pollicis — the posterior 
tibial nerve lying to its fibular side, with the venae comites surrounding the 
artery. 

Comment. — If the incision be at the upper part of the lower third of 
the artery, the vessel will be found upon the flexor longus digitorum. If 
the incision be at the lower part of the lower third, the upper part of the 
internal annular ligament must be cut. 




G 

— 1 

"1 



Fig. 61. — Ligation of Right Posterior Tibial behind Internal Malleolus: — A, Branch 
of internal saphenous vein; B, Branch of internal saphenous nerve; C, Internal annular ligament 
(incised); D, Tendon of flexor longus hallucis; E, Tendon of flexor longus digitorum; F, Tendon 
of tibialis posticus ; G, Posterior tibial artery ; H, H, Posterior tibial vense comites ; I, Posterior tibial 
nerve. 



LIGATION OF POSTERIOR TIBIAL 

BEHIND INTERNAL MALLEOLUS. 

Position. — As for ligation of the lower third. 
Landmarks. — Internal malleolus. 

Incision. — About 5 cm. (2 inches) in length, placed about 1.3 cm. (\ 
inch) posterior to and parallel with the inner malleolus (Fig. 51, K). 



LIGATION OF POSTERIOR TIBIAL. 



Operation. — Incise skin and superficial fascia — during which branches 
of the internal saphenous vein are encountered (Fig. 61). Expose the in- 
ternal annular ligament and divide it over the vessels — the artery being found 
in the interval between the flexor longus digitorum and flexor longus hallucis, 
surrounded by its vena; comites and with the nerve upon its fibular side (Fig. 
62). 




Fig. 62. — Cross-section of the Right Leg just Above the Ankle: — A, Extensor 
proprius pollicis; B, Anterior tibial vessels and nerve; C, Peroneus brevis; D, Peroneus longus; 
E, Flexor longus pollicis; F, Tibialis anticus; G, Extensor proprius pollicis; H, Tibialis posticus; 
I, Flexor longus digitorum; J, Posterior tibial artery, veins, and nerve; K, Tendo Achillis. (The 
cross-section modified from Braune.) 

Comment. — Keep the knife pointed toward the tibia, in making the 
incision. Avoid opening the sheaths of the tendons. Behind the internal 
malleolus and posterior surface of the tibia are four compartments, which, 
passing from tip of malleolus toward heel, are — first, a canal in the annular 
ligament for the posterior tibial muscle tendon — a second canal for the flexor 
longus digitorum tendon — a third space occupied bv the posterior tibial 
artery, its venae comites, and the posterior tibial nerve — and a fourth canal 
for the flexor longus hallucis. 



114 OPERATIONS UPON THE ARTERIES. 

SURGICAL ANATOMY OF PERONEAL BRANCH OF POSTERIOR 
TIBIAL ARTERY. 

Description. — Arises from posterior tibial about 2.5 cm. (1 inch) below 
inferior border of popliteus — and curves (with convexity outward and upward) 
obliquely outward and downward to fibula — descending thence close to inner 
border of fibula, to lower third of leg, where the anterior peroneal is given off 
(which pierces the interosseous membrane to front of leg) — thence passes, 
as posterior peroneal, to inferior tibiofibular joint and external malleolus. 
It is accompanied by two venae comites. 

Relations. — (From origin to bifurcation.) Anteriorly : (from above 
downward) Tibialis posticus; fibrous bed between origins of tibialis posticus 
and flexor longus hallucis. Posteriorly: (from above downward) Soleus; 
flexor longus hallucis (completing fibrous canal of artery). 

Branches. — Muscular, nutrient, anterior peroneal, communicating, 
posterior peroneal, external calcanean. 

Line of Artery. — From middle of popliteal space, on level of lower 
border of tubercle of tibia, arching slightly outward and then downward 
along inner border of posterior surface of fibula. For purposes of ligation, 
the artery is represented by a line from posterior border of head of fibula 
to point midway between external malleolus and outer margin of tendo 
Achillis. 

Indications for Ligation. — Rare — except for wounds, when the vessel 
is cut down upon at the point wounded. 

Sites of Ligation. — Upper part — rare, owing to depth. Middle — usual 
site (Fig. 51, L). 



LIGATION OF PERONEAL BRANCH OF POSTERIOR TIBIAL 

IN MIDDLE OF LEG. 

Position. — Patient rests on shoulder and chest of opposite side; knee 
flexed; leg on antero-internal surface. Surgeon on outer side, cutting from 
below on right, and from above on left. 

Landmarks. — External border of fibula. 

Incision. — About 7.5 cm. (3 inches) in length — parallel with and just 
behind external border of fibula, with its center over the middle of the leg— 
which falls behind the peronei muscles (Fig. 51, L). 

Operation. — Incise skin and superficial fascia. Branches of the external 
saphenous nerve and external saphenous vein are apt to be encountered here 
(Fig. 63). Expose the soleus (which, at this site, no longer arises from the 
fibula) and retract it upward and inward (incising its lower fibers if any be 
found attached to the fibula at this height). Divide the deep fascia behind 
the peronei. Expose the flexor longus hallucis and incise through its thick- 
ness, close to the fibula — until the fibrous canal of which it forms the roof 
is reached. Divide the aponeurotic canal and expose the artery lying near 
the fibula, with its venae comites 



SURGICAL ANATOMY OF THE EXTERNAL PLANTAR ARTERY. 1 15 




Fig. 63. — Ligation of Right Peroneal in Middle of Leg: — A, Branch of external saph- 
enous nerve; B, Branch of external saphenous vein; C, Gastrocnemius, retracted inward; D, 
Soleus, retracted' upward and inward ; E, Peroneus longus ; F, Peroneus brevis ; G, Tibialis posticus; 
H, Flexor longus hallucis, incised, showing roof of aponeurotic canal enclosing vessels ; I, Peroneal 
artery ; J, Peroneal venae comites. 



SURGICAL ANATOMY OF EXTERNAL PLANTAR BRANCH OF POS- 
TERIOR TIBIAL. 

Description. — Larger of two terminal branches given off by posterior 
tibial at inner ankle. Passes from beneath internal annular ligament, obliquely 
forward and outward across sole of foot to base of fifth metatarsal — thence 
curves forward and inward to base of first interosseous space — where it 
anastomoses with communicating branch of dorsalis pedis, to form plantar 
arch. Two venae comites accompany the artery. 

Relations. — First part (from inner ankle-joint to base of fifth meta- 
tarsal): Rests on os calcis; flexor accessorius; flexor minimi digiti. Covered 
by — skin; superficial fascia; plantar fascia; abductor hallucis; flexor brevis 
digitorum and abductor minimi digiti. Lies between — flexor brevis digi- 
torum and abductor minimi digiti. Accompanied by — external plantar 
nerve and two venae comites. Second part: (Plantar arch; from base of 
fifth metatarsal to proximal end of first interosseous space.) Rests on — - 
proximal ends, and corresponding interosseous muscles, of second, third, 
and fourth metatarsals. Covered by — skin; superficial fascia; plantar fascia; 
flexor brevis digitorum; tendon of flexor longus digitorum; lumbricales; 
branches of internal plantar nerve; adductor hallucis. 



n6 



OPERATIONS UPON THE ARTERIES. 



Branches. — Muscular, calcaneal, cutaneous, anastomotic, articular, pos- 
terior perforating, digital. 

Line of Artery. — First Part: from point midway between tip of internal 
malleolus and great tubercle of os calcis, to base of fifth metatarsal. Second 
Part: — from base of fifth metatarsal, to posterior part of ball of great toe. 




Fig. 64. — Incisions for Liga- 
tion of Plantar Arteries: — A, 
Incision for external plantar in sole of 
foot; B, For internal plantar in sole of 
foot; C, For external plantar arch at 
base of first interosseous space; D, Ball 
of heel; E, Base of fourth toe; F, Base 
of first toe. 




Fig. 65. — Ligation of Right External Plan- 
tar in Sole of Foot: — A, Superficial fascia; B, 
Abductor minimi digiti; C, Flexor brevis digitorum; 
D, Deep plantar fascia; E, External plantar artery; 
F, F, External plantar venae comites; G, External 
plantar nerve. 



Indications for Ligation. — Wounds and aneurisms. 
Sites of Ligation. — At origin — more frequent site. In the sole. Plantar 
arch — rare. (Fig. 64, A, C.) 



LIGATION OF EXTERNAL PLANTAR 

IN SOLE OF FOOT. 

Position. — Patient supine; foot resting upon heel, steadied upon a sup- 
port. Surgeon at foot of table. 

Landmarks. — Ball of heel; fourth toe. 

Incision. — Along arch of foot, in a line from ball of heel to fourth toe 
— about 6 cm. (2 J inches) in length (Fig. 64, A). 

Operation. — Divide skin, superficial fascia, fatty areolar tissue, and 
plantar fascia. Expose the gap between the flexor brevis digitorum and 
abductor minimi digiti — in which the artery is found, with accompanying 
nerve and veins (Fig. 65). 



LIGATION OF INTERNAL PLANTAR. 



117 



SURGICAL ANATOMY OF INTERNAL PLANTAR BRANCH OF POSTE- 
RIOR TIBIAL. 

Description. — Smaller of two terminal branches given off by posterior 
tibial at inner ankle — passing forward along inner side of sole, generally 
to first interosseous space, to anastomose with fifth plantar digital of com- 
municating branch of dorsalis pedis. 

Relations. — First covered by abductor hallucis — then lies between 
abductor hallucis and flexor brevis digitorum — and, toward distal end, is 
covered by skin and fascia. 

Branches. — Muscular, cutaneous, articular, anastomotica, superficial 
digital. 

Sites of Ligation. — At origin — more frequent. In sole. (Fig. 64, B.) 

LIGATION OF INTERNAL PLANTAR 

AT ORIGIN". 

Position — Landmarks — Incision — Operation. — As for ligation of ex- 
ternal plantar at origin. 




A 



Fig. 66. — Ligation or Right Internal Plantar Artery in Sole of Foot: — A, Super- 
ficial fascia; B, Abductor hallucis; C, Flexor brevis digitorum; D, Internal plantar artery; E, E, 
Internal plantar venae comites; F, Internal plantar nerve. 

LIGATION OF INTERNAL PLANTAR 

IN SOLE OF FOOT. 

Position. — As for external plantar. 

Landmarks. — Heel; great toe. 

Incision. — Along arch of foot, in line from point of heel to great toe — 
about 6 cm. (2^ inches) in length (Fig. 64, B). 

Operation. —Divide skin, superficial fascia, and fattv areolar tissue. 
Expose the gap between the abductor hallucis and flexor brevis digitorum — 
in which interval the artery is found (Fig. 66). 



Il8 OPERATIONS UPON THE ARTERIES. 

TEMPORARY OR PROVISIONAL LIGATION OF ARTERIES. 

Definition. — The temporary arrest of circulation in an artery by means 
of a ligature carried beneath the vessel — whereby the artery is drawn upon 
until the flow ceases, but is not tied. 

Indications. — Where it is desired to control for a time the arterial circu- 
lation during the steps of an operation — or where a ligature is placed about 
an artery in advance of, or preparatory for, any emergency which may arise 
— (e. g., temporary ligature of common carotid in the removal of a tumor 
of the neck, or of the femoral in popliteal aneurism). 

Operation. — All the steps, up to the exposure of the sheath of the artery, 
are similar to those for an ordinary ligation. At this point, instead of opening 
the sheath, the sheath itself is isolated (unless a common sheath contain 
other important structures). A stout ligature (preferably broad) that will 
not cut is passed beneath the sheath. The two ends of the ligature are not 
tied upon the artery, but are simply grasped by clamp-forceps in the hands 
of an assistant (or knotted into a loop). When it is desired to control all 
flow through the vessel, the assistant simply lifts the artery slightly from 
its position — the under wall of the artery is thereby pressed into contact 
with the upper wall by the loop of the ligature, over which the artery makes 
an angle, and the flow ceases. On relaxing tension, the artery falls back 
into its normal position and the flow continues. Where no further need 
exists for this control, one end of the loop is drawn upon and the ligature 
slips out from under the artery. Where the temporary is converted into a 
permanent ligature, the ligature is tightened in the ordinary manner — although, 
were this likelihood foreseen, it would be better to open the sheath of the 
artery at first and place the temporary ligature directly around the artery 
proper. Floss silk is especially useful for provisional ligatures. 

Comment. — As this subsidiary operation is generally resorted to in 
advance or in the course of some more major operation, the steps of the 
temporary ligation are modified by those of the main operation. 

INTERMEDIATE LIGATION, OR LIGATURE EN MASSE. 

Definition. — Ligature en masse for parenchymatous hemorrhage is a 
method of controlling hemorrhage which comes from no definite vessels, or 
from inaccessible sources, or as a capillary oozing. 

Description. — A fully curved needle, armed with catgut, is made to 
enter the tissue to one side of the site from which the flow comes — passes 
deeply into the parts, and, in emerging, more or less completely surrounds 
the area of hemorrhage — which is controlled by the tightening of the ligature. 
Or, in hemorrhage from a larger area, a curved needle, held in a holder, 
may be made to surround the area from which parenchymatous bleeding 
comes by circumventing that area with a purse-string ligature introduced 
by several consecutive insertions of the needle — at, for instance, four points 
of a circle. The ends of beginning and ending of this catgut ligature are 
then drawn and knotted — only tightly enough to control hemorrhage, and 
not tightly enough to strangulate the parts. 

ARTERIORRHAPHY. 

Definition. — Suture of an artery. 

Indications. — Arteriorrhaphy may be required in longitudinal wounds 
of an artery; in limited transverse or oblique wounds; in transverse wounds 



ARTERIORRHAPHY. 



II 9 



of more than half the circumference; in complete division, or in division 
with partial resection (the resected portion not exceeding more than about 
2 cm. — I inch). 

Exposure of the Vessel and Repair of a Longitudinal or Partial 
Transverse Wound of an Artery by Suture of the Outer Coats. — (i) 
With aseptic precautions, the sheath of the artery is exposed and opened with 
minimum injury to vessel and surroundings. If the circulation have not 
been temporarily controlled by a constrictor, or some form of pressure, the 
artery is clamped above and below the injury with special forceps (e. g., 
Billroth's, with broad blades protected by pieces of rubber drainage-tubes 
drawn over them; or probably better, by means of floss silk lightly tied or 
looped). (2) Seize, in turn, the lips of the wounded artery with a pair of 
oculist's rat-tooth fixation-forceps. Using a fully curved and round con- 
junctival needle (or straight floss-needle, or cambric needle) threaded with 





Fig. 67. — ARTERIORRHAPHY IN COMPLETE CIRCULAR DIVISION OF AN ARTERY (MURPHY'S 

Method) : — A, Intussusceptum, with sutures passing through outer and middle coats; B, Intus- 
suscipiens (split to aid invagination) with sutures passing through all coats. 
Fig 68. — C, Same showing all sutures tied. 

twisted silk of exact size as eye of needle (that hemorrhage may not occur 
through the needle-hole which the silk has not fully filled), penetrate the 
tunica adventitia and muscularis, down to (but not through) the intima. 
The lips of the wound are pierced immediately opposite each other. The 
knots are interrupted — are from 1 to 2 mm. (about -^ to TTr inch) apart — 
enter artery about 1.5 mm. (y 1 ^ inch) from edge of wound — and are lightly 
tied with a reef-knot, avoiding inversion of the lips of the artery. The sheath 
of the artery is separately sutured over the vessel, if possible. The skin 
wound is closed as usual. A wound in the long axis of the artery tends to 
gape least, and a transverse wound most. If the artery be divided through 
one-half of its circumference, it should be entirely divided and re-united by 
some method of suture, preferably by invagination. 

Repair of Complete Transverse Division of an Artery by Invagina- 
tion. — Murphy's Method: The artery is united end-to-end by invagination. 



120 OPERATIONS UPON THE ARTERIES. 

A piece of finely twisted silk is threaded upon two needles — one of which 
is passed through the outer and middle coats of the proximal end (intussus- 
ceptum), in the transverse axis — then both needles, held side by side, are 
simultaneously passed through all coats of the distal end (intussuscipiens) 
about 7 to 12 mm. (J to J inch) from its free end, passing from within outward. 
Two or three of these sutures are applied equidistantly. The distal end is 
then slit a short distance (the slit not extending as low as the sutures) to aid 
in invagination — which is then accomplished by traction upon the sutures — 
which are, after invagination is complete, tied lightly with reef-knot. Rein- 
forcing sutures are placed at the line of junction, and uniting the lips of the 
slit — but do not pass through the intima of the intussusceptum. (See Figs. 
67 and 68.) 

Repair of Longitudinal or Oblique Wounds of the Larger Vessels, 
or of Complete Transverse Division, by Combination Cobbler's Stitch 
through all the Coats, and Interrupted Sutures through the Outer Coats. 
— Based upon the fact that union between approximated endothelial coats 
of the blood-vessels -rapidly occurs — and realizing the advantages of a suture 
which, while applied through very limited available extent of tissue, must 
bring together relatively broad surfaces of vessel-wall closely and strongly, 
in order to withstand the constant hammering and distention of the arterial 
and distention of the venous flow, the author suggests a method (original 
as far as he knows) of tightly and firmly approximating relatively broad sur- 
faces of the tunica intima of the larger vessels, especially arteries, by means 
of the cobbler's stitch through all the coats, followed by reinforcing the margins 
of the wound by interrupted sutures through the tunica adventitia and tunica 
muscularis. 

Irrespectively of the theoretical consideration it has been found, practically, 
that through-and-through suturing of all the coats of a vessel is not followed 
by harmful consequences. Therefore, although the necessity for guarding 
against this complete penetration of all coats now no longer exists, yet in the 
present method, notwithstanding all coats are actually pierced, the effect of 
the suture is most probably not that of a through-and-through suture — since 
the method of its application makes it likely that little, if any, portion of the 
stitch itself comes into contact with the blood-current, owing to the recession 
upon the inner aspect of the vessel and protection of the stitches by consequent 
contact with and union of adjacent intimre, corresponding to and caused by 
the external ridging produced by this particular form of suturing. 

The materials used for the continuous through-and-through suture are the 
finest chromic gut, having sufficient tensile strength — and, for the interrupted 
sutures of the outer coats, fine silk. Fine silk or fine Pagenstecher thread 
may be used in the primary as well as in the secondary suturing. The finest 
possible special round needles which will carry the suture should be used — 
with eyes nearly as large as the diameter of the head of the needle as mechani- 
cally possible, that the thread following the needle-puncture may completely 
fill the puncture in the vessel-wall. Where feasible, a straight needle long 
enough to be held in the fingers should be used — or, where necessary, shorter, 
straight needles or curved ones may be employed in a convenient form of 
needle-holder. During the placing of the sutures the opposite edges of the 
artery are held in contact and ready to receive the suture by two delicate dis- 
secting (ribbed, but not toothed) forceps in the fingers of an assistant, who 
so approximates the lips of the vessel- wound as to aid the operator materially 
in the process of suturing (Fig. 69, F, F). Prior to closing the main (skin) 
wound, in all methods of vessel-suturing, the newlv sutured vessel-wall should 



ARTERIORRHAPHY. 



121 



be supported, where possible, by suturing muscle, or other resistant neighboring 
tissue, in such a way as to protect the vessel at this site. 

While necessarily the caliber of a vessel thus sutured is encroached upon, 
in the case of the larger vessels this encroachment is not sufficient to be of 
practical importance — and, in the case of smaller vessels, the remaining lessened 
channel is better than no channel at 
all, which was the case in formerly 
ligating all wounded vessels. 

(A) Suture of a Longitudinal 
Vessel-wound. — The opposite lips of 
the wound are each grasped with for- 
ceps and held in contact (Fig. 69, 
F, F). The needles (one held be- 
tween the operator's thumb and first 
finger of each hand) are made to 
enter the lips of the wound on oppo- 
site sides and pass in opposite direc- 
tions (Fig. 69, B, B), beginning just 
above one of the limits of the wound, 
at a distance of about 1.5 mm. ( T *g- 
inch) from a line that would represent 
a continuation of the vessel-wound 
(Fig. 69, A). The needles now 
change hands, and are made to pass 
through all the coats in an opposite 
direction, about 3 mm. (| inch) fur- 
ther along the wound. This char- 
acteristic cobbler's stitch is continued 
as indicated in the figure — the thread 
being drawn tightly at the end of each 
stitch. Finally, the two ends of the 
thread are tied in a reef knot at the 
far end of the wound. This method 
of suturing will ridge up the vessel 
at the site of its application — approxi- 
mating two surfaces of intima slightly 
more than 1.5 mm. (y 1 ^- inch) in 
width, and a little longer than the 
length of the wound — and causing the 
two free margins of the lips of the 
wound to lie parallel, presenting them- 
selves prominently forward in lateral, 
but not edge-to-edge, contact, as 
shown in Fig. 69. This lateral con- 
tact is now converted at the margins 

into a partial, if not complete, edge-to-edge contact by the reinforcing 
interrupted silk sutures — which enter the tunica adventitia about 1 mm. 
(less than y 1 ^ inch) from the free margin (Fig. 69, D, D) — pass through 
the tunica adventitia, and all or a greater part of the tunica muscularis — 
to emerge just between the tunica muscularis and tunica intima — thence, 
crossing the inner aspects of the vessel-wall wound, enter between the 
tunica intima and tunica muscularis of the opposite lip — to emerge 
through the tunica adventitia at a distance corresponding with the point 




Fig. 69. — Repair of Longitudinal 
Wound of Artery by Combination Cob- 
bler's Stitch through all Coats, and 
Interrupted Sutures through Outer 
Coats, as suggested by the Author: — A, 
Beginning of cobbler's stitch through all coats; 
B, B, Needles in act of passing through same 
opening in opposite directions, in characteristic 
cobbler fashion; C, C, Three interrupted 
sutures through outer coats, ready to be tied; 
D, D, Two interrupted sutures tied, passing 
through outer coats. 



122 



OPERATIONS UPON THE ARTERIES. 



of entrance — after which the opposite ends of the interrupted sutures are 
tied (Fig. 69, C, C) — thus practically bringing the margins of the opposite 
lips into close contact — and thereby affording opportunity of union not only 
between the relatively broad surfaces of endothelial coats, but also between 
the free edges of the corresponding coats at their margins. While this 
method is of application to vessel-wounds in general, it is particularly applicable 
to brittle, atheromatous vessels, in which it is difficult to make the ordinary 
form of suture hold. 

(B) Suture of an Oblique Vessel-wound. — There is no special principle 
involved in suturing wounds which cross the long axis of a vessel obliquely 





' 



« 



"•:-. 



Fig. 70. — Repair of Oblique Wound 
of Artery by Combination Cobbler's 
Stitch through all Coats, and Inter- 
rupted Stitches through Outer Coats, 
as suggested by the Author: — A, A, 
Cobbler's stitch being completed by needles 
passing through all coats in opposite direc- 
tions; B, B, Interrupted sutures passing 
through outer coats. 



Fig. 7 1 . — Repair of Complete Trans- 
verse Division of Artery by Combina- 
tion Cobbler's Stitch through all 
Coats, followed by Interrupted Su- 
tures through Outer Coats, as sug- 
gested by the Author: — A, A, Needles 
passing in opposite directions through all 
coats, in act of placing cobbler's stitch; 
B, Superficial tier of interrupted stitches 
through outer coats, showing three untied 
and two tied. 



not already brought out in the longitudinal suturing. In proportion as such 
wounds correspond with the long axis of the vessel does the technic corre- 
spond with that of the longitudinal wounds — and in proportion as the wound 
approaches complete encircling of the vessel, though in an oblique direction, 
is the technic equivalent to that employed in complete transverse division of 
the vessel (Fig. 70). 

(C) Suture of Complete Transverse Division of a Vessel. — The above 
principles are here applied to a circumferential wound of a vessel — the edges 
of the wounded vessel-wall representing a transverse section rather than a 
longitudinal or an oblique one. In carrying the cobbler's stitch around the 
vessel it is well to calculate that corresponding extents of the circumference 



ARTERIORRHAPHY. 



123 



are being taken up, so that no redundancy of any one aspect will be left in 
terminating the line of suture (Fig. 71, A, A). The tier of reinforcing 
interrupted sutures is applied in the manner described for longitudinal wounds 
(Fig. 71, B). 





Fig. 72. — Circular Arteriorrhaphy in Complete Division of an Artery: — A, Method of 

Salomoni and Tomaselli — interrupted sutures through all coats. 

■fig- 73- — B, Same, method of Gliick — interrupted sutures through outer coats, protected by 

cylinder of decalcihed bone, ivory, or rubber. 

Other Methods of Suturing Arteries. — Besides the methods above 
described, end-to-end union may be accomplished by suturing through all 




Figs. 74, 75, 76. — Circular Arteriorrhaphy, after Complete Division of an Artery:— 

The methods of Bougie. 



the coats of both ends, after the manner of Salomoni and Tomaselli (Fig. 72., 
or by the method of Gliick (Fig. 73), or by one of the methods of Bougie 
(Figs. 74, 75, 76). 



124 



OPERATIONS UPON THE ARTERIES. 



CLOSURE OF WOUNDS OF LARGER ARTERIES BY SPECIAL RUBBER 

PLASTER. 

BREWER'S METHOD. 

Description. — The portion of the vessel involved in the wound is encircled 
by several turns of elastic plaster. This plaster is made by coating long, 
narrow, ribbon-like sheets of thin, pure rubber with the material of which 
zinc oxid plaster is coated, and is sterilized by formaldehyd vapor. Following 
the application of the plaster, the wounded vessel is further reinforced, where 
possible, by bringing neighboring muscle or connective tissue into contact 
with it in the process of suturing the wound. 

Position; — Landmarks; — Incision. — Determined by the special oper- 
ation. 

Operation. — Having exposed the wounded vessel, the artery is isolated 




Fig. 77. — Brewer's Method of Closing Arterial Wounds by Special Rubber 
Plaster: — The femoral artery is exposed at the apex of Scarpa's triangle. The circulation is 
temporarily controlled by special artery clamps applied above and below the wound (here 
represented by a longitudinal slit in the vessel-wall). The adhesive rubber ribbon has been 
drawn under the vessel and is held taut by forceps. 

sufficiently for manipulation, is brought out of its sheath, and is gently com- 
pressed above and below the wounded site by the fingers, or by some special 
clamps which compress just enough to control the circulation without injuring 
the vessel. By means of pledgets of gauze wet with ether the wall of the 
artery is cleaned of blood and made dry, so that the rubber plaster will adhere. 
A strip of the rubber ribbon is now carried under the artery, with its adhesive 
surface next the vessel, the two corners of its end grasped by forceps, preferably 
of the artery -clamp kind (Fig. 77). The shorter end of the adhesive strip 
which has been carried beneath the artery is now brought up over and into 
contact with the vessel, and the longer end of the plaster carried over the shorter 
end by reversing the position of the ends of the plaster, so that they will now 



ANEURISMORRHAPHY. 



be in the position shown in Fig. 78. During this manoeuver the plaster is 
kept gently on the stretch, so as to subject the vessel to slight pressure and 
compression in the act of rolling the plaster around it. Two or more encirclings 
are made, as deemed necessary — after which the plaster is cut transversely 
and the artery allowed to drop back into its original position (Fig. 79). The 





Fig. 70. — Same : — The vessel has been sur- 
rounded by several turns of the rubber plaster, 
which is then cut transversely. 



Fig. 78. — Brewer's Method of Clos- 
ing Arterial Wounds by Special Rubber 
Plaster: — The end of the rubber plaster be 
neath the vessel is brought into contact with 
the vessel by carrying the forceps grasping 
this encl to the left — after which the longer 
end is carried over to the right. 

neighboring parts, where possible, are so sutured as further to support the 
wounded vessel. The main wound is sutured without drainage. 



ANEURISMORRHAPHY 

OPERATION FOR RADICAL CURE OF ANEURISM BASED UPON 

ARTERIORRHAPHY. 

MATAS'S OPERATION. 

Description. — The objects sought in this plastic procedure are the restor- 
ation of the blood-current and the obliteration of the aneurismal sac. The 
accomplishment of these objects is dependent for its success upon the readily 
occurring union of the general endothelial lining, which, continuous with that 
of the vessel, not only covers the common arterio-aneurismal orifice between 
vessel and aneurismal sac, but the interior of the sac as well. In operat- 
ing upon the saccular form of aneurism (Fig. 81) the aneurismal sac is laid 



126 



OPERATIONS UPON THE ARTERIES. 



open; — the aneurismal orifice is exposed and closed by suture in such a way 
as not to interfere with the circulation through the main vessel — and the cavity 
of the sac is completely obliterated by suturing its walls and overlying integu- 
mentary parts to its floor. In operating upon the fusiform variety (Fig. 89) 
in those cases where the walls are pliable and available, the circulation through 
the part is restored by forming a new blood-channel by suturing the adjacent 
floor of the sac over a temporarily placed rubber tube — which is withdrawn 
just before tightening the final sutures — after which the aneurismal sac is 
obliterated. In the fusiform variety, where the aneurismal walls are so bound 
down or are of such consistency as to make it impossible to bring them together 
to form a new channel; the two orifices are closed by suture and the restoration 

of the blood-current is permanently aband- 
oned (Fig. 91) — the sac, however, being ob- 
literated in the usual manner. 

Indications. — The method of restoration 
of current is applicable in all cases where — 
(a) a distinct sac exists (whether fusiform 
or saccular); (b) where the proximal circula- 
tion can be temporarily controlled; and (c) 
where the sac-wall is sufficiently free and 
pliable to be manipulated in the necessary 
manner. Where the aneurismal sac is not 
sufficiently free and pliable, the obliteration 
of the current, as well as the sac, is necessary. 
In the fusiform type of aneurism two open- 
ings of the main vessel exist — one at either 
end, generally with a groove connecting them. 
Here a new blood-channel is built over a 
rubber tube temporarily inserted into the 
openings of the aneurism and lying in the 
groove, or along the bed between the open- 
ings — thus restoring the circulation. In the 
saccular type of aneurism a single opening of 
the main vessel exists. Here the margins of 
the opening are brought together by suture, 
leaving the artery intact and capable of carry- 
ing on circulation. The operation differs 
slightly in the different types. The opera- 
tion, in general, will be described in the 
case of saccular aneurisms — after which the 
special features of the other types will be 
pointed out. 
The advantages of this method of operating are the following: — Restoration 
of blood-current through the main vessel in favorable cases; — simpler tech- 
nic; — less traumatism; — elimination of any ligaturing; — no disturbance of 
structures in vicinity of aneurismal sac; — preservation of collateral circula- 
tion; — usual prompt healing by the approximation of the integumentary 
coverings to the floor of the sac. 

Position; — Landmarks; — Incision. — Will be determined by the special 
aneurism. 

Operation. — (A) For the closure of the arterio-aneurismal opening 
and the restoration of the blood-current in the artery, in saccular aneu- 
risms : — (1) Where the position of the aneurism permits, the entire circulation 




Fig. 80. — Aneurismorrhaphy: 
■ — First stage of operation. Ex- 
posure of popliteal aneurism — a 
fusiform aneurism laid open, show- 
ing two openings and an intervening 
groove. (Modified from Matas.) 



ANEURISMORRHAPHY. 



127 



through the limb is controlled by a rubber constrictor. Otherwise the aneu- 
rism is exposed and the artery is controlled proximally by Matas's special 
curved aneurism clamp-forceps, Crile's clamps, by a traction-loop around the 
vessel, or by some other device. In cases where the entire circulation of the 
limb cannot be preliminarily controlled, profuse bleeding may occur, on laying 
open the aneurism, from the collaterals opening into the sac. (2) A free 
median incision of the overlying parts is made — after which the adjacent 
structures are retracted away from the presenting aspect of the aneurismal sac 
(Fig. 80). (3) The sac is now incised from end to end — guarding against 
sudden hemorrhage from one or more unknown collaterals, which may be 
temporarily controlled by thrusting a gauze pack tightly into the aneurismal 
sac. (4) All laminated fibrin is rubbed off the walls of the aneurism with gauze 
— and the walls themselves are also briskly rubbed with gauze to promote 
endothelial proliferation. (5) The main arterio-aneurismal opening is now 
closed by two tiers of interrupted chromic gut sutures. The sutures of the 
first tier pass through the margins of the orifice without entering the lumen of 
the artery and without piercing the entire thickness of the aneurismal wall- 
extending somewhat beyond both poles of the opening. They are planned 
so as to afford broad serous surfaces for union (Fig. 81). A rubber tube, 




Fig. 81. — Aneurismorehaphy: — Operation to restore current in saccular aneurism — 
first stage. Placing of interrupted sutures through borders of arterial opening into aneurism — 
leaving channel of vessel intact. (Modified from Matas.) 

temporarily inserted within the lumen of the vessel, may be used to aid suturing, 
if necessary — as in fusiform aneurisms. The lumen of the artery is thus not 
interfered with, and the circulation is 'preserved. The sutures of the first tier 
are now tied (Fig. 82), the knots being to one side of the median line — thus 
approximating the two sides of an ellipse (Fig. 81) into a median straight 
line (Fig. 82). A second or reinforcing tier of interrupted sutures is now 
placed — not only strengthening the primary line of sutures against leakage, 
but also ridging up the floor of the aneurismal sac and helping, thereby, to 
obliterate it (Fig. 82). The details of the two tiers of suturing are better 



128 



OPERATIONS UPON THE ARTERIES. 



seen in Fig. 87. Both of these tiers of suture may be continuous (Fig. 86). 
(6) The mouth of any collateral vessel opening into the sac is closed by two 




Fig. 82. — Aneurismorrhaphy: — Operation to restore current in saccular aneurism — 
second stage. The interrupted sutures through the borders of the arterial opening have been 
tied. A second tier of interrupted sutures, overlying and outlying the first, is being placed 
through the inner coats of the aneurismal sac — which, upon being tied, will bury the first tier 
and ridge up the floor of the aneurism in the median line. (Modified from Matas.) 

or more interrupted sutures placed as shown in Fig. 91, and tied as shown 
in Fig. 92. (7) The tourniquet around the limb, or the special clamps upon 
the vessel, is now removed and the efficiency of the suturing tested. All hemor- 







___>c> 


i 






/*t 







F- 




Fig. 83. — Aneurismorrhaphy: — Cross-sec^on of the parts involved in the operation where 
the current is restored, together with the complete obliteration of the sac of the aneurism: — A 
Integuments; B, Aneurismal sac; C, Walls of blood-channel; D, First tier of sutures, approxi- 
mating walls of blood-channel; E, Second tier of sutures, approximating floor of sac over first 
tier; F, F, Sutures through walls and into floor of aneurism, approximating former to latter; 
G, Suture through margin of integuments and into floor of sac, over second tier; H, Restored 
blood-channel. (Modified from Matas.) 

Fig. 84. — Aneurismorrhaphy : — Cross-section of the parts involved in the operation where 
the blood-channel, together with the aneurismal sac, are completely obliterated. The figures 
are the same as in the above, except that H here represents the obliterated blood-channel. (Mod- 
ified from Matas.) 



ANEURISMORRHAPHV. 



129 



rhage in the general wound is controlled by ligature. (8) The empty aneu- 
rismal sac is next obliterated. This is accomplished by means of four sutures 
placed in the manner shown in Fig. 88. Four interrupted sutures of chromic 
gut, kangaroo-tendon, or silkworm gut are placed, as indicated in the 
illustration, in the floor of the aneurism by means of an ordinary curved needle 
or Reverdin needle, passing deeply into but not through the walls of the sac 
(Fig. 88, A, A). Each one of the free ends of these four loops is now brought 
out through the corresponding aspect of the outer wall (or roof) of the aneurism 
and overlying integumentary parts, by means of a Reverdin needle (Fig. 88, 
B, B), which is passed through the skin on into the aneurism through all the 





Fig. 85. — Aneurismorrhaphy: 
— Final stage of operation. The 
walls of the aneurism-sac and the 
integuments are sutured to the floor 
of the sac over gauze rollers, thus 
firmly approximating the former to 
the latter. (Modified from Matas.) 



Fig. 86. — Aneurismorrhaphy : — Operation to 
restore current in saccular aneurism. In the present 
instance both tiers of sutures are continuous — the first 
has been placed and is being tightened — and the second 
is being placed. The principles of the operation, other- 
wise, are the same as in the corresponding operation 
by interrupted sutures (Figs. Si and 82). (Modified 
from Matas.) 



intervening structures. These sutures are tightly tied over small gauze rolls — 
thereby firmly infolding and compressing the roof of the aneurismal sac and 
all overlying structures, to the floor of the sac and the central elevation, or 
ridging, formed by the two tiers of suturing. The result of the tying of these 
sutures and the consequent relation of the parts are shown in the diagrammatic 
cross-section (Fig. 83). The two flaps thus inturned consist of aneurism-wall 
and integumentary coverings — the approximation obliterating all dead space 
between the wall of the sac and the integuments, on the one side, and the floor 
of the sac, on the other. (9) The main wound is now closed by a median 
line of interrupted sutures (Fig. 85). 



l 3° 



OPERATIONS UPON THE ARTERIES. 




Fig. 87. — Aneurismorrhaphy: — Showing in greater detail the steps of the last two illus- 
trations (Figs. 81 and 82). All but two of the first tier of interrupted sutures have been placed 
and tied. The second tier is being placed and is in the act of burying under the first tier and 
ridging up the floor of the aneurism. (Modified from Matas.) 

(B) For the closure of the arterio-aneurismal opening and the resto- 
ration of the blood-current in the artery, in fusiform aneurisms : — The 

preliminary and final steps are the same as just described. Owing to the 
distance between the orifices which usually exists in fusiform aneurisms, and 




Fig. 88. — Aneurismorrhaphy: — Operation to restore current in saccular aneurism — 
third stage. The second tier of interrupted sutures is here shown tied. A, A, Placing interrupted 
sutures, with curved needle, in floor of aneurism, preparatory to approximating the aneurism- 
wall to the floor of the aneurism; B, B, Reverdin needle in act of drawing the sutures (just placed) 
through the aneurism wall. (The final tying of these four sutures is shown in Fig. 83, F, F, 
and Fig. 85.) (Modified from Matas.) 



ANEURISMORRHAPHY. 



131 




Fig. S9. — Aneurismorrhaphy : — Operation to restore current in fusiform aneurism. 
Suturing borders of opening and of connecting groove over a temporary rubber tube — the ends 
of which are seen projecting into the lumen of the vessel, at either end. The interrupted form 
of suture is here shown. (Modified from Matas.) 

the inability to form a channel along this intervening distance without some 
form of support, a rubber tube (the end of a catheter, for instance) is inserted 
into these openings and made to occupy the groove which generally exists 
between the two openings (Fig. 89). Over this tube the sac is sutured, as 




Fig. 90. — Aneurismorrhaphy: — Operation to restore current in fusiform aneurism. 
The interrupted sutures placed in the preceding figure have been tied at the two ends — 
while those in the center are being held apart during the withdrawal of the rubber tube, 
after which these also are tied. Some of the second tier of sutures are shown in place, ready 
to be tied. (Modified from Matas.) 



132 



OPERATIONS UPON THE ARTERIES. 




Fig. 91. — Aneurismorrhaphy: — Operation to obliterate openings and channel in fusiform 
aneurism. All of the first tier of sutures is placed, and the lower half tied, obliterating the lower 
opening and half of the channel. The lower half of the second tier is placed, but not tied. 
Sutures are seen in the mouth of a collateral, opening upon the wall of the sac. (Modified 
from Matas.) 

in Witzel's gastrostomy (page 959). All the sutures are placed before any 
are tied. The end sutures are then tied over the tube — when the tube is with- 




Fig. 92. — Aneurismorrhaphy: — Operation to obliterate openings and channel in fusiform 
aneurism — second stage. The second tier of suturing (which is here a continuous suture) is 
shown, entirely concealing the first tier and all evidence of openings and channel. A, A, Placing 
interrupted sutures, with curved needle, in floor of aneurism, preparatory to approximating the 
aneurism wall to the floor of the aneurism; B, B, Reverdin needle in act of drawing the sutures 
(just placed) through the aneurism wall. (The final tying of these four sutures is shown in 
Fig. 83, F, F, and Fig. 85.) The closure of the mouth of a collateral vessel is shown in the wall 
of the aneurism-sac. (Modified from Matas.) 



OPERATION FOR RADICAL CURE OF ARTERIOVENOUS ANEURISMS. 133 

drawn through the separated middle sutures, which are then tied (Fig. 87). 
The operation is completed in the general manner — a second tier of sutures 
being used here as elsewhere. 

(C) For the obliteration of both blood-channel and aneurismal sac, 
in fusiform aneurisms : — In cases of fusiform aneurism where it is found that, 
owing to such circumstances as the adhesion of the floor of the aneurismal sac 
to some unyielding structure, or owing to some pathologic change preventing 
the necessary manipulation of the sac-wall, a new blood-channel cannot be 
made, nothing remains but to close both arterio-aneurismal orifices and the 
intervening groove without attempting to bring about the restoration of 
circulation. In these cases both the orifices and intervening groove are closed 
by a double tier of sutures, placed in the ordinary manner (Figs. 91 and 92), 
after which the sac is treated in the usual way. The cross-section of an 
obliterating operation of this nature is shown in Fig. 84. 

Comment. — (I) Union takes place between the serous surfaces lining 
the sac (the arteries being mesoblastic in origin). (2) The sutures should 
take strong hold in the walls of the sac. (3) Superfluous sac-wall is to be 
excised. (4) The perisaccular structures should not be disturbed more than 
absolutely necessary, as most of the nourishment of the sac comes to it through 
these structures. (5) Firm pressure should be applied in the outer dressing 
over the aneurism site, to aid in keeping in contact the parts held by the 
transfixion sutures. (6) In the case of the limbs, the part is to be elevated 
and kept swathed in cotton-batting to maintain the temperature of the part, 
applying artificial heat if necessary. 



OPERATION FOR THE RADICAL CURE OF ARTERIOVENOUS ANEU- 
RISMS, WITH PRESERVATION OF CIRCULATION IN ARTERY AND 
VEIN. 

MATAS-BICKHAM OPERATION. 

Description. — This technic consists, as suggested by the author, in the 
application to the arteriovenous type of aneurisms of the method of radical 
cure which Matas applies to ordinary arterial aneurisms- — with the modifications 
necessitated by the special forms of arteriovenous aneurisms, thus preserving 
the integritv of both artery and vein and sparing the patient the great risk 
attendant upon the loss of circulation through one or both of these vessels. 
Where this form of operation can be carried out, the composite aneurismal sac 
is exposed — its double blood-supply controlled — the sac incised — the openings 
of artery and vein sutured- — and the common sac either obliterated by approxi- 
mation of its walls, as carried out in the operation of aneurismorrhaphy — or 
the sac is excised in whole or in part and the orifices closed by suturing. 

Indications. — In all cases — (a) where a distinct sac exists;- — (b) where 
the arteriovenous circulation through the aneurism can be controlled prior 
to incising the sac; — and (c) where the structure and surroundings of the sac 
will admit of the necessary manipulations. It is a known fact that the nature 
of arteriovenous aneurisms cannot always be determined clinically, and are 
often only discovered when the site has been exposed by operation. But it 
would be warrantable to expose the aneurism in every appropriate case and, 
where feasible, make an attempt to preserve the circulation through both 
vessels. 

Position; — Landmarks; — Incision. — Determined by the special opera- 
tion. 



134 



OPERATIONS UPON THE ARTERIES. 



Operation. — (A) Upon the Varicose-aneurism Type of Arterio- 
venous Aneurisms, with Preservation of the Sac— In these cases an 
aneurismal sac intervenes between artery and vein, communicating with 
both vessels by separate mouths (Fig. 93). After temporarily controlling 




Fig. 93. — Varicose-aneurism Type of Arteriovenous Aneurism of Left Common 
Femoral Artery and Vein — showing the Application to this Class of Aneurisms of the 
Matas Method of Operating upon Ordinary Aneurisms: — The opening of the femoral 
artery into the common aneurismal sac is shown on the right, with interrupted Lembert gut 
sutures in position, ready to be tied. The opening of the femoral vein is seen on the left, with 
similar Lembert sutures in position. On the left of the sac two gut sutures are in the act of 
being placed, which, when tied, will approximate the roof of the sac (including skin and inter- 
vening tissues, which are not here shown) to the floor of the sac. Similar sutures will approxi- 
mate the roof and floor of the sac upon the right. (From Bickham, "Annals of Surgery," 
May, 1904.) 



the circulation through the involved vessels, lay open the intervening aneuris- 
mal sac, locate both the arterial and venous openings into it, and close them 
off by fine chromic gut Lembert sutures applied interruptedly, followed 
by obliteration of the sac by suturing its roof, including the overlying parts, 
to its floor. It is to be remembered that an endothelial layer usually lines 
the cavity of an arteriovenous aneurism, and is especially apt to be present 
near the openings into the sac; although the absence of an endothelial lining 



OPERATION FOR RADICAL CURE OF ARTERIOVENOUS ANEURISMS. 135 

would not seem to be a contraindication to the application of this method, 
as the surfaces of even a pure connective-tissue sac could be roughened by 
curettement or friction to promote adhesion of its walls. This lechnic is 
shown in Fig. 93. 

(B) Operation upon the Aneurismal-varix Type of Arteriovenous 




Fig. 94. — Aneurismal-varix Type of Arteriovenous Aneurism of Left Common 
Femoral Artery and Vein: — The opening of the femoral artery into the varicosed vein is 
shown, with interrupted Lembert gut sutures in position, ready to be tied. The longitudinal 
incision in the vein, for approaching the arteriovenous opening (and which is here made somewhat 
unnecessarily long) is shown in the act of being closed by two methods of suturing — above, by 
the continuous Lembert of the outer coats — below, by interrupted ordinary sutures of the outer 
coats. (From Bickham, "Annals of Surgery," May, 1904.) 

Aneurisms, with Preservation of the Sac. — In these cases there is a vari- 
cosed dilatation of a vein, caused by the force of the arterial circulation poured 
into it through a direct communication from an artery, without an intervening 
aneurismal sac (Fig. 94). After temporarily controlling the circulation 
through the involved vessels, make a longitudinal incision through the enlarged 
and varicosed vein for as limited an extent as would seem to afford approach 



i3 6 



OPERATIONS UPON THE ARTERIES. 



to the opening into the vein, and so placed as to lie directly opposite this 
communicating opening from the artery, retract the lips of this wound in the 
vein, thus exposing the interior of the vein and the arterial communication, 
suture up the opening of the artery into the vein in the usual Matas manner, 
and then close the incised vein by a continuous lateral suture of, approxi- 
mately, the Lembert type. Fig. 94 illustrates tin's technic. Owing to the 
fact, in aneurismal-varix cases, that foreign material will be left in contact 
with the venous current by this manner of suturing (which does not apply in 
the varicose-aneurism cases), with the consequent theoretical possibility of 



U^" 




Fig. 95. — Same as Fig. 94, showing a continuous Lembert gut suture, which, having been 
passed through the outer coats of the thickened vein at the angle of junction of vein and artery, 
and knotted, is passed on between the coats of the vein until its varicosed cavity is entered very 
near one end of, and immediately above, the first tier of interrupted sutures — and is then made 
to bury i 1 this first tier and itself in continuous Lembert fashion — and, emerging at the opposite 
angle of junction of vein and artery, is tied in the same manner as at its entrance. (This suture 
is not yet tightened throughout.) (From Bickham, "Annals of Surgery," May, 1904.) 

pieces of the suture forming emboli, it would be well to use very fine gut for 
this suture, and to tie very small, closely cut knots. Or it would be better 
still to bury-in the row of interrupted Lembert sutures, closing off the arterial 
opening, by means of a continuous buried suture introduced from without 
entirely through the vein, at one of the angles of junction of artery and vein, 
passing in continuous Lembert fashion above the interrupted sutures, through 
part of the thickness of the wall of the vein, and out through the entire thickness 
of the vein at the opposite angle of junction of artery and vein, in very much 
the same manner as a subcuticular suture is passed, and so placed that the 
suture throughout its entire length and its points of entrance and exit to and 



OPERATION FOR RADICAL CURE OF ARTERIOVENOUS ANEURISMS. 137 

from the vein is also buried, which, in the case of a thickened, varicosed vein 
would be easier of accomplishment than in a normal vein. This second tier 
of suturing is shown in Fig. 95. 

(C) Operation upon the Varicose-aneurism Type of Arteriovenous 
Aneurisms, with Excision of the Sac. — More recently, successful artery- 
suturing and vein-suturing have been demonstrated, and these principles may 
be applied to arteriovenous aneurisms. In those cases of the varicose- 
aneurism type where both arterial and venous circulation can be controlled 
proximally to the sac, and the sac exposed by dissection, the aneurismal sac 




Fig. 96. — Varicose-aneurism of Left Common Femoral Artery and Vein, treated 
by Excision of the Sac, followed by Suturing of the Openings in the Vessels: — Upon 
the right, a small elliptical piece of the sac is shown connected with the arterial opening, with 
the first tier of interrupted Lembert gut sutures in position, ready to be tied. Upon the left, 
a similar elliptical piece of sac has been left connected with the venous opening. The first 
row of Lembert sutures has been tied, and a second tier of ordinary sutures through all the coats 
is being applied, burying in the first tier. Fig. 96 is the same as Fig. 93, with the sac excised. 
(From Eickham, "Annals of Surgery," May, 1904.) 

may, in appropriate cases, be excised up to very near the arterial and venous 
openings into it, and these openings then closed by a row of interrupted 
Lembert gut sutures, followed by a second burying-in row through the free 
margins of the small portion of the sac left around the jug-like opening into 
the artery and vein, as shown in Fig. q6. 

(D) Operation upon the Aneurismal-varix Type of Arteriovenous 
Aneurisms, with Excision of the Sac. — In those cases of the aneurismal- 
varix type, where, similarly, both the arterial and venous circulation may be 
arrested proximally to the arteriovenous communication, and this site of 



138 



OPERATIONS UPON THE ARTERIES. 



communication be exposed by dissection, the artery and enlarged vein may, 
in appropriate cases, be severed from each other by an incision through the 
connecting opening, made parallel with artery and vein, and these openings 
closed by lateral suture with fine gut or silk, the openings left by the incision 
of the connection between artery and vein being, in the aneurismal-varix, less 
jug-like and with less free margin than in the varicose aneurism. This technic 




Fig. 97. — Aneurismal-varix of Left Common Femoral Artery and Vein, treated 
by Severance of Vessels from each other, followed by Suturing of their Openings: — 
On the right, interrupted gut sutures are shown passing through the outer coats of the artery, 
ready to be tied. On the left, a continuous Lembert gut suture through the outer coats is shown 
closing the venous opening. Fig. 97 is the same as Fig. 94, with the vessels cut apart. (From 
Bickham, "Annals of Surgery," May, 1904.) 



is shown in Fig. 97. If necessary, these openings left by the liberating 
incision could be trimmed into elliptical shapes. 

Comment. — While recognizing that it is ideal to excise the aneurismal 
sac of a varicose aneurism and suture up the openings in the artery and vein, 
and to cut apart artery and vein in an aneurismal-varix and somewhat similarly 
suture up the openings in the vessels which the severing of the common con- 
nection between them has left, leaving the circulation intact in both class of 
cases — yet there must occur cases in which there is difficulty of satisfactorily 
exposing the parts, or where there is difficulty in, and contraindication to, 
the removal of the sac of a varicose aneurism, or the cutting apart of artery 
and vein in an aneurismal varix- — and in such cases the Matas method would 



OTHER OPERATIONS FOR RADICAL CURE OF ANEURISM. 139 

seem to be a desirable technic. And while one feature is common to all of 
these more modern methods, and that is, the retention of the circulation through 
artery and vein, yet it may be questioned where, from the circumstances of 
the case, it is optional, whether the Matas method would not really be preferable 
in dealing with the varicose aneurism type of cases; for it would seem the 
suturing together of the roof and floor of the sac would strengthen the suturing 
of the arterial and venous openings into the sac and make secondary hemor- 
rhage less likely, and also accomplish the end with less traumatism. 



LIGATION FOR RADICAL CURE OF ANEURISM. 

Description. — Several methods of applying ligatures for the radical cure 
of aneurism have been adopted — either as a means alone or in conjunction 
with other steps. 

Methods. — (I) Antyllus's Method ("Old Method"): — The sac is incised 
— the clots are turned out — and the involved artery ligated above and below 
the sac. (2) Anel's Method: — Ligature of the involved artery just above 
(proximal to) the sac. (3) Hunter's Method: — Ligature of the main vessel in- 
volved at some distance above (proximal to) the sac, so that one branch, at 
least, intervenes between sac and ligature, thereby only partly cutting off the 
circulation through the sac. (4) Brasdor's Method: — Ligature of the main 
artery involved beyond (distal to) the sac, entirely cutting off the circulation 
through the sac. (5) YVardrop's Method: — Ligature of one or more of the 
distal branches. (6) Extirpation: — Ligature of the main vessel (and collateral 
branches) above and below the sac, with extirpation of the aneurism — with 
or without opening the sac. 



OTHER OPERATIONS FOR RADICAL CURE OF ANEURISM. 

Acupuncture. — A method of treating aneurisms by the introduction of 
long needles into their sacs. Several long, fine needles are simultaneously 
introduced, by the safest route, through overlying integuments, into and 
through the wall of the aneurism — and on beyond, until in contact with the 
opposite wall. Here they are allowed to quietly rest for several hours, and 
are then withdrawn. Repetition of this process may be resorted to upon 
successive occasions. Coagulation is thus favored. 

Needling (Macewen's Operation). — The introduction of one or two 
long needles into the sac, with irritation of its wall. A long, fine needle is 
introduced, by the safest route, through skin and connective tissue, into and 
through the wall of the aneurism — and is pushed on until in contact with 
the inner surface of the opposite wall. The wall of the aneurism is then 
gently irritated by a process of scratching, by means of the point of the needle 
— which is then withdrawn. The interior of the sac should be evenly irritated 
throughout, or at different sites consecutively. This direct irritation of the 
wall should be only great enough to produce a reparative exudation together 
with a deposit of fibrin — and thus white thrombi are formed upon the surface 
of the sac. Two or more needles may be used simultaneously in a large sac, 
and several hours may be consumed in the process — and their use repeated 
upon successive occasions. 

Introduction of Wire. — A fine cannula is introduced, by the safest route, 
through skin, fascia, and wall of aneurism, into the cavity of the sac. Through 
this cannula several vards of fine wire (according to size of aneurism) are 



140 OPERATIONS UPON THE ARTERIES. 

introduced and left, the cannula being withdrawn. Cure is effected by the 
clotting of blood upon this wire meshwork. Catgut, silk, horsehair, and the 
like have been used — but silvered copper wire has proved the most satis- 
factory. 

Comment. — The method of aneurismorrhaphy is preferable to all others 
in those cases where the circulation can be controlled prior to opening the 
sac. Second to this, or where this method cannot be applied, one of the 
methods of ligation, with or without extirpation of the sac, should be used. 



ARTERIAL FORCIPRESSURE. 

Definition. — Pressure of artery by artery-clamp forceps. 

Description. — This is the ordinary method of controlling hemorrhage 
by seizing arteries in a wound, upon an amputation stump or in the course 
of any operation — by means of clamp or hemostatic forceps. The forceps 
are allowed to remain in situ for a period of time after their application, but 
are not twisted upon their axis (as in the following operation). The hemostat 
should grasp the bleeding end of the artery, and as little else as possible. 
Where circumstances allow, the artery to be subjected to forcipressure should 
be cleared of surrounding connective tissue by a stroke or two of the knife, 
especially in the case of the larger vessels. In the case of the smaller arteries, 
the forceps may be removed and nothing further done, with fair certainty 
that no further bleeding will occur from the crushed vessels. In the case 
of the larger arteries, a catgut ligature should be applied over the point of the 
forceps, just prior to their removal (Fig. 293, B). 

Comment. — In some operations, as in vaginal hysterectomy by the 
clamp method, the forceps are left in the wound for twenty-four or forty- 
eight hours or longer. 



ARTERIOSTREPSIS. 

Definition. — Torsion of an artery by means of artery-clamp forceps. 

Description. — The operation consists in the seizing of the divided end 
of an artery with forreps and twisting it through two or three revolutions, in 
the direction of its long axis — causing a rupture and retraction of its inner 
and middle coats wdthin the outer coat. A clot forms and organizes upon 
and in the roughened inner coats and is protected by the outer coat. The 
twisting should cease short of causing a complete severance of the end of the 
artery. This is the common method of arresting hemorrhage from the 
smaller vessels bleeding in a wound or upon the surface of an amputation 
stump, and its use should be confined to such vessels, although the femoral 
artery has been successfully controlled by torsion (occurring in accidents). 
The technic differs slightly in the application of arteriostrepsis to small and 
medium vessels: (a) Upon Smaller Arteries: — seize the extremity of the bleed- 
ing vessel with catch-forceps, including as little tissue, other than the sheath 
of the artery, as possible — draw it out from its connections and twist it around 
two or three times and release the hold, (b) Upon Medium Arteries: — seize 
the extremity of the severed artery, in its long axis, with catch-forceps, and 
draw the vessel out of its sheath for about 1.3 to 2 cm. (J to f inch). With 
a second pair of catch-forceps, grasp the bared artery about 1.3 cm. (^ inch) 
from its extremity, at a right angle to its long axis, and hold steadily. Then 



TREATMENT OF VASCULAR NEOPLASMS. 141 

rotate the vessel two or three times by means of the terminal forceps, and 
let go. Thus the proximal forceps prevent the artery from being twisted in 
its sheath, which would sever its vasa vasorum in their passage from the 
sheath to the arterv. Only that portion of the artery, therefore, between the 
clamps is twisted. Ligation is generally to be preferred to arteriostrepsis. 



THE TREATMENT OF VASCULAR NEOPLASMS BY INJECTION OF 
WATER AT HIGH TEMPERATURE. 

WYETH'S OPERATION. 

Description. — This method of treatment consists in the injection into 
the substance of vascular neoplasms (angeiomata) of water at a temperature 
of from 190° to 212 F. and over — the object being immediately to coagulate 
the blood and albuminoids of the tissues. The vascular tumors thus far 
treated by the author of the operation have been arterial angeiomata (cirsoid 
aneurisms), capillary angeiomata ('' mother's marks"), and venous angeiomata 
(cavernous nawi). 

Instruments. — Syringe with metallic cylinder and an adjustable piston, 
and needles of various sizes. The water is usually gotten from some im- 
mediately adjacent vessel in which it has come to a boil, and under all aseptic 
precautions. In cirsoid aneurisms and in the larger cavernous narvi, where 
the water should be kept at the boiling-point during the use of the needle 
and syringe, the author of the operation has devised a long metallic instru- 
ment under the cylinder of which a Bunsen burner is held during operation. 

Operation. — (1) The region of the injection is rendered aseptic in the 
usual manner. The operation is done under complete narcosis. The quan- 
titv and temperature of the water will vary according to the size and nature 
of the growth. (2) In arterial and venous angeiomata the needle is carried 
deeply into the substance of the growth and from 30 to 60 minims of water 
are thrown out in one site — the needle is then withdrawn from 1.3 to 2.5 
cm. (J to 1 inch) and about the same amount injected — and the same steps 
repeated in different sites until the whole tumor is solidified. While using 
water of a temperature sufficiently high to coagulate the blood and albu- 
minoids of the neighboring tissues, it should not be delivered into the part 
so exceedingly hot nor with such pressure as to cause subsequent sloughing 
of the overlying parts. Evidence of sufficient distention of the part to dis- 
continue the injection in that particular site is given by slight bleaching 
of the skin. (3) In capillary angeiomata, especially upon delicate parts, 
water a little loelow boiling (about 190 F.) should be used — and only about 
two to six minims thrown in at a single puncture — beginning at the periphery 
of the growth. Sloughing is more apt to occur in the capillary angeiomata. 
The injection may be repeated in from seven to ten days, if necessary. (4) 
A surgical dressing is then applied and the part kept at rest. 

Comment. — (i) Especial care is advised in the cases of angeiomata of the 
neck and scalp, because of oedema. (2) No more than from five to six 
ounces should be injected at one sitting in the largest growths and very much 
less in most cases. (3) Sloughing of the tissues from the action of the boiling 
water deposited in their midst is possible, and is an important consideration 
in localities when this occurrence would be functionally or cosmetically serious. 



CHAPTER II. 

OPERATIONS UPON THE VEINS. 

PHLEBOTOMY. 

Definition. — Incision of a vein, or venesection. A method, now rarely 
practised, of depletion by bleeding, for its effect upon the system. One of 
the veins of the elbow is usually selected. 

Indications. — Pulmonary engorgement; engorgement of the right heart; 
many inflammatory states in sthenic persons. 

Preparation. — Bend of elbow shaved. 

Position. — Patient, holding arm extended and abducted, sits upright, 
that warning by approaching syncope may be given. Surgeon stands in 
front and to right of either arm. 

Instruments and Accessories. — Lancet or bistoury; fillet or constrictor; 
round object to grasp (roller bandage); a graduated "bleeding-bowl" or 
measure; gauze compress; bandage. 

Operation. — Apply the constrictor around the lower third of the arm, 
that the return venous flow may be obstructed and veins about the elbow 
made prominent, while not firmly enough to obstruct the arterial flow. The 
grasping and manipulating of the fingers about some object will aid the 
distention of the veins. The most prominent vein at the bend of the elbow 
is now selected. The median basilic vein (which is crossed by the internal 
cutaneous nerve and is parallel with and separated from the brachial artery 
by the bicipital fascia) is generally chosen — because of its greater prominence, 
and because of being steadied by the underlying bicipital fascia. The median 
cephalic vein (which is covered by skin and fascia alone and rests upon the 
external cutaneous nerve) is often chosen — and is also sometimes the more 
prominent. The vein is steadied by pressure of the left thumb just below 
the intended incision. The lancet or bistoury, with its back to the arm, is 
thrust through the skin over the vessel, and into the distended vein beneath 
— and is made to cut its way upward and outward at a single stroke — cal- 
culating to sever, in an oblique direction, about two-thirds of the vein. Upon 
removing the thumb, the bleeding is allowed to continue until approaching 
faintness indicates a sufficient loss — when the constrictor is removed, the 
gauze pad placed over the wound, and a figure-of-eight bandage applied 
to the elbow. 

Comment. — (i) If bleeding continue, the vein is to be entirely severed 
— and the wound may even be enlarged and the vessel doubly ligated. (2) 
The internal saphenous vein may also be used. 



PHLEBORRHAPHY. 

Definition. — The suture of a wound in a vein, without occluding the 
caliber of the vessel. 

142 



LATERAL LIGATION OF VEINS. 



143 



Indications. — Where, in the case of a limited wound to one of the larger 
veins, it is desired to control hemorrhage without permanently destroying 
the function of the vein by transverse ligation — and where the wound is too 
long for lateral ligation. 

Operation. — Having well exposed the vein and controlled the hemorrhage 
from the vessel by distal compression (by constrictor, digital compression, 
or temporary ligature), one of the lips of the wounded vein is steadied with 
fine forceps,' while a fine needle, armed with finest catgut, pierces this lip, 
including, if possible, only the external and part of the middle coat. The 
opposite lip is similarly steadied and similarly pierced, in the opposite direction 




Fig. 98.— Phlebokrhaphy:— Forceps are seen everting lip of wound for passaj 

interrupted sutures. 



of needle and 



(penetrating part of the middle and the entire thickness of the outer coat). 
By tying the ligatures carefully, the two lips are brought into even apposition. 
Interrupted sutures, closely applied, will more safely repair the wound than 
continuous suture (Fig. 98). 

Comment. — This method is especially applicable where (a) the wound 
is longitudinal (and therefore the lips tend to lie parallel), and (b) where 
the wound extends in any one direction a distance greater than equivalent 
to the diameter of the lumen. Sometimes instead of approximating lip to 
lip, the edges of the wound are sutured upon themselves. 



LATERAL LIGATION OF VEINS. 

Description. — The application of a ligature to the wall of a vein for 
the purpose of closing a wound in the vein without obliterating its lumen. 
Indications. — Wound of one of the larger veins, where it is desired to 



144 OPERATIONS UPON THE VEINS. 

control hemorrhage without destroying the function of the vein by transverse 
ligation. 

Operation. — Having controlled hemorrhage and brought the vein well 
into the field of operation, seize the two lips of the wounded vein in a single 
bite of a pair of dissecting forceps — draw them outward from the wall of 
the vein in the form of a small cone (whose apex is formed by the forceps) — and, 
around the base of the cone, tie, with a reef-knot, a ligature of fine chromicized 
catgut, relaxing the tension upon the cone at the moment of tightening the 




F'&- 99- — Lateral Ligation of a Vein : — Forceps are shown drawing outward and puckering 
together the wounded lateral wall of a vein, around which a ligature is being tied. 

knot — and thus throwing into folds the walls of the rent in the vessel very 
much as one puckers together the mouth of a sac with a draw-string. The 
ligature is cut short and the temporary compression relaxed — and the wound 
closed as in an ordinary ligation (Fig. 99). 

Comment. — This method is applicable where the wound does not extend 
in any one direction a distance equivalent to the diameter of the lumen. 
Transverse wounds gape more than longitudinal ones and are thus especially 
suitable for this form of ligature. 



TRANSVERSE LIGATION OF VEINS. 

Description. — The ordinary ligation of a vein (in contradistinction to 
lateral ligation). 

Indications. — Wounds; arteriovenous aneurism; simple and suppurative 
phlebitis; thrombosis; angeiomata. 

Operation. — As for ligation of arteries, in general principle. 



TEMPORARY LIGATION OF VEINS. 

Description. — As for same operation upon arteries (page 118). 
Indications. — As in temporary ligation of an artery (e. g., temporary 



PHLEBECTOMY. 145 

ligation of internal jugular vein in removal of tumor of neck — or while ligating 
or suturing a wound of the vein). 

Operation.— Same, practically, as for the corresponding operation upon 
the arteries (page 118). 



VENOUS LIGATION EN MASSE. 

Description. — For parenchymatous hemorrhage. 

Operation. — Practically identical with intermediate ligation, or ligation 
en masse, described under Arteries (page 118). 



VENOUS FORCIPRESSURE. 

Description. — A method of control of venous hemorrhage, corresponding 
with arterial forcipressure (page 140) — though of more limited application. 



PHLEBOSTREPSIS. 
Description. — Corresponding with arteriostrepsis (page 140). 

ACUPRESSURE OF VEINS. 

Description. — Pressure of vein by needle — the pressure being applied 
directly or indirectly. Rarely resorted to at present. Formerly much used 
for varicose veins, nasvi, and venous hemorrhage. 

Operation. — Several methods of acupressure exist, differing in but minor 
details. The following is the most generally applicable method : The needle 
(or pin) enters the skin near the involved vein — passes under the vein as closely 
as possible — and emerges from the skin on the opposite side. Over this 
needle, in a figure-of-eight fashion, a silk ligature is wound — thus compressing 
the vein between needle and ligature. 



PHLEBECTOMY. 

Description. — Excision of a vein, in whole or in part. 

Indications. — The usual causes for which veins are removed are vari 
cosity (e. g., excision of varicosed veins of leg, or of a varicocele) and throm- 
bosis, especially suppurative (e. g., excision of internal jugular for suppurative 
thrombosis following middle-ear disease). 

Operation. — As illustrative of the technic of phlebectomy in general, 
partial excision of the internal saphenous will be described for varicosity 
of that vein and its branches — the operation consisting in the total removal 
of sections of the vein and its branches at intervals along its course. (1) 
The site and course of the varicose veins are previously marked with nitrate 
of silver stain (on the preceding day, to allow of darkening), that the land- 
marks may not be lost during operation. The limb is shaved. An Esmarch 
is generally used to control hemorrhage. (2) Over the course of the vein 
(or slightly to one side, or obliquely crossing it) incisions of from 8 to 15 cm. 



146 OPERATIONS UPON THE VEINS. 

(3 to 6 inches) are made at intervals — extending, if necessary, from the inner 
side of the foot to the saphenous opening in the thigh. These incisions are 
especially placed over the most marked groups of veins — and those nearer 
the saphenous opening are usually the first attacked. The skin and bands 
of fibrous tissue binding down the vein are divided and the involved veins 
exposed. The vein and its branches are entirely isolated to the extent of 
the incision, by blunt and sharp dissection. The vein is then gently drawn 
upon, so as to bring into the open wound as much of itself and branches as 
possible — when it is gut-ligatured at both ends, each branch being also liga- 
tured — after which the main vein and its branches are cut away. This site 
of operation is then packed with gauze, until removal at all indicated sites is 
accomplished — to allow of cessation of all bleeding before suturing. (3) 
The edges of the skin wound are then sutured with silk, or silkworm-gut — 
after which the limb is dressed, immobilized, and slightly elevated. 

Comment. — (1) The removal of the vein in sections appears to give as 
good, or better, results as the attempt to remove the entire vein. (2) Avoid 
wounding the veins in operation, which increases the difficulties. (3) Avoid 
including a nerve filament in the ligature, which has caused much subsequent 
pain. 



INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. 

Description. — Injection of normal salt solution into the venous circula- 
tion. 

Indications. — Hemorrhage; shock; sepsis; suppression of urine; and other 
conditions. 

Preparation of Normal Salt Solution. — The physiological salt solution 
for man is a mixture of 0.6 of 1 per cent, of sodium chlorid in water (approx- 
imately, one dram of sodium chlorid to one pint of water). This mixture is 
to be sterilized and used at a temperature of 115 to 120 F. — being allowed 
to pass from an elevated funnel or jar through a rubber tube and special 
cannula into the vein. The salt may be sterilized first — or the solution may 
be sterilized after preparation. The operation is conducted aseptically 
throughout. 

Preparation. — Patient's elbow is shaved and protected by aseptic dressing 
(if occasion allow). 

Position. — Patient recumbent; arm extended, abducted and supine. 
Surgeon on right side of both arms — or on right side of right, cutting from 
above; and on left side of left, cutting from below. 

Instruments and Accessories. — Scalpel; dissecting forceps; artery- 
clamp forceps; funnel; rubber tube; bulbous-pointed cannula; aneurism- 
needle; ligature; suture; needle and holder; constrictor for arm; gauze com- 
press, cotton and bandage. 

Operation. — The most prominent vein at the bend of the elbow is chosen 
(see Phlebotomy, page 126). If the vein be prominently marked, incise 
directly over and parallel with it. If not marked, incise obliquely across 
the known course of the- median basilic vein, the incision running parallel 
with the direction of the bicipital fascia. Proceed carefully until the vein is 
located. Expose from 2.5 to 4 cm. (1 to i| inches) of the vein. Pass two 
catgut ligatures beneath the vein, about 2.5 cm. (1 inch) apart — and tie the 
distal one permanently (Fig. 100). With a pair of sharp-pointed scissors, 
curved on the flat, an oblique incision is made through one-half of the vein, 
between the two ligatures, the apex of the "V" pointing distally. Into this 



INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. 



147 



oblique opening into the vein, the cannula (after seeing that no air is in the 
instrument) is introduced — and the proximal ligature is tightened about it 
with a friction-knot. Through this is allowed to flow, by static pressure, as 
much fluid as is indicated (generally from one to six pints). The cannula 
is then withdrawn — the proximal ligature is tightened and tied permanently 




C- -n— U- 



Fig. 100. — Intravenous Infusion of Normal Salt Solution : — A, Bandage tourniquet ; E, 
Median basilic vein; C, Distal (to heart) ligature tied about vein; D, Proximal (to heart) ligature 
loosely placed and ready to be tied about vein ; E, Forceps grasping tongue of wound in vein just 
made by curved scissors ; F, tip of cannula about to enter vein and around which ligature will be tied ; 
G, Stop-cock. 



— and the vein completely severed. The wound is sutured and the dressing 
applied. 

Comment. — The fluid may be thrown into an open vein in a stump — 
or any convenient vein in a wound may be opened. The basilic vein itself 
may be used — or the internal saphenous. Szumann's infusion solution con- 
sists of six parts of sodium chlorid, one part of carbonate of soda, and one 
thousand parts of sterilized water, heated to a temperature of no° to 112 F. 
Szumann's formula may be expressed as follows: 

R. Sterilized water 32 oz. 

Sodium chlorid 1 ^2 dr. 

Sodium carbonate 15 gr. 

Mix and heat to 1 io° or 1 1 2° F. 



CHAPTER III. 

OPERATIONS UPON THE LYMPHATIC GLANDS 

AND VESSELS. 

SURGICAL ANATOMY OF THORACIC DUCT. 

Course and Relations. — (i) Abdominal portion: — (from origin to dia- 
phragm); — Begins in abdomen at receptaculum chyli, on anterior surface 
of second lumbar vertebra, lying behind and to right side of aorta and between 
aorta and right crus of diaphragm. At aortic opening in diaphragm (in 
front of twelfth dorsal vertebra) it still lies to right of aorta and has vena 
azygos major to its right. (2) Thoracic portion : — (from diaphragm to 
superior thoracic opening) ; — Runs up posterior mediastinum between aorta 
and vena azygos major, in front of sixth to twelfth dorsal vertebr&\ Opposite 
to fifth dorsal vertebra it passes to left behind esophagus and aortic arch 
to enter superior mediastinum, whence it emerges through superior thoracic 
opening into root of neck, (a) In Posterior Mediastinum (from below 
upward) — Anteriorly ; pericardium; esophagus; arch of aorta. Posteriorly ; 
sixth to twelfth dorsal vertebras; anterior common ligament; right inferior 
intercostal arteries; vena azygos minor (sometimes one of left middle inter- 
costal veins and vena azygos tertia). Left; thoracic aorta. Right; vena 
azygos major; right pleura, (b) In Superior Mediastinum; — anteriorly; 
first part of left subclavian artery. Posteriorly ; upper dorsal vertebra? 
(first to fifth.) Left ; left pleura. Right ; esophagus. (3) Cervical por- 
tion : — (from superior thoracic opening to termination) ; — From superior 
thoracic opening it ascends on left side of neck to level of seventh cervical 
vertebra — curves thence downward, forward, and outward, arching over 
apex of left pleura — passing in front of subclavian artery, scalenus anticus 
muscle, vertebral vein — and behind left internal jugular vein, and behind 
and then externally to left common carotid artery — and, receiving left jugular 
lymphatic trunk, empties into left innominate vein at junction of left internal 
jugular and left subclavian veins. 

Course and Relations of Right Lymphatic Duct. — About 1.3 to 2 
cm. (^ to f inch) in length — formed by union of subclavian and jugular 
lymphatic ducts — passes downward and inward — and empties into venous 
circulation at junction of right internal jugular and subclavian veins. 



SUTURE OF THORACIC DUCT. 

Description. — Suture of the thoracic duct is indicated in wounds of 
the duct occurring from external injury, or in the course of an operation. 

Operation. — The method of suturing the thoracic duct is similar to 
that employed in suturing a vein (see Phleborrhaphy, page 142). Having 
completed the technic of suturing the duct itself, the neighboring tissues 
should be drawn over and sutured about the wound in the duct, to aid in 
closing and reinforcing the sutured site — and the overlying skin should be 



SURGICAL ANATOMY OF AXTERO-LATERAL ASPECT OF NECK. 149 

sutured throughout and pressure applied. Minimum nourishment should 
be administered to the patient, to keep the duct as empty as possible until 
union of the wound has occurred. 

Comment. — If possible, the right duct should be similarly dealt with. 



LIGATION OF THORACIC DUCT. 

Description. — The thoracic duct, where completely severed by accident, 
has been ligated, and recovery lias followed — although there has been a 
question as to whether, in such cases, a branch of the main duct has not 
existed and maintained the circulation. Suturing, however, is always prefer- 
able to ligation, where possible. Where ligation is performed, the technic 
is the same as that for ligating a vein (pages 143 and 144). 

Comment. — The right lymphatic duct may also require ligation if its 
divided ends be discovered in a wound. 



SURGICAL ANATOMY OF ANTERO-LATERAL ASPECT OF NECK. 

Boundaries of Antero-lateral Aspect of Neck. — Superiorly : lower 
border of body of inferior maxilla, and imaginary line from angle of inferior 
maxilla to mastoid process. Inferiorly : upper border of clavicle. Ante- 
riorly : median line of neck. Posteriorly : anterior border of trapezius. 

Subdivisions of Quadrilateral Surface of Neck. — (a) Anterior Triangle 
— divided, by digastric muscle above and anterior belly of omohyoid below, 
into submaxillary, superior carotid, and inferior carotid triangles, (b) 
Posterior Triangle — divided, by posterior belly of omohyoid, into occipital 
and subclavian triangles. 

Anterior Triangle. — Boundaries, anteriorly: median line of neck, 
from chin to sternum. Posteriorly : anterior margin of sternomastoid 
muscle. Superiorly : lower border of body of inferior maxilla, and line 
from angle of inferior maxilla to mastoid process (base). Inferiorly: at 
sternum (apex). This triangle is subdivided into submaxillary, superior 
carotid, and inferior carotid triangles. 

Submaxillary Triangle. — Boundaries : Superiorly — lower border of 
inferior maxilla, and line from angle of inferior maxilla to mastoid process. 
Inferiorly — posterior belly of digastric and stylohyoid. Anteriorly — anterior 
belly of digastric (or middle line of neck). Coverings: integument; super- 
ficial fascia; platysma; deep fascia; branches of facial nerve; branches of 
superficialis colli nerve. Floor: anterior belly of digastric; mylohyoid; 
hyoglossus. Contents : Muscles — styloglossus, stylopharyngeus. Ligaments 
— stylomaxillary (separating anterior from posterior part of triangle). Ar- 
teries — external carotid, posterior auricular, temporal, internal maxillary, 
mylohyoid branch of inferior dental, facial with submaxillary and submental 
branches, internal carotid. Veins — internal jugular, facial, submaxillary. 
Nerves — facial, pneumogastric, glossopharyngeal, mylohyoid branch of in- 
ferior dental. Other Structures— parotid gland, submaxillary gland, lymph- 
atic glands. 

Superior Carotid Triangle. — Boundaries : Superiorly — posterior belly 
of digastric. Inferiorly — anterior belly of omohyoid. Posteriorly — anterior 
border of sternomastoid. Coverings: integument; superficial fascia; pla- 
tysma; deep fascia; branches of facial nerve; branches of superficialis colli 



150 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 

nerve. Floor: parts of thyrohyoid; hyoglossus; inferior constrictor of 
pharynx; middle constrictor of pharynx. Contents: Arteries — common 
carotid; internal carotid; external carotid; superior thyroid; lingual; facial; 
occipital; ascending pharyngeal. Veins — internal jugular; superior thyroid; 
lingual; facial; occipital (sometimes); ascending pharyngeal. Nerves — 
descendens hypoglossi; hypoglossal; pneumogastric; sympathetic; spinal 
accessory; superior laryngeal; external laryngeal. Other Structures — larynx; 
pharynx; lymphatic glands. 

Inferior Carotid Triangle. — Boundaries: Superiorly — anterior belly 
of omohyoid. Anteriorly — middle line of neck. Posteriorly — anterior margin 
of sternomastoid. Coverings: integument; superficial fascia; platysma; 
deep fascia; descending branch of superficialis colli nerve. Floor: scalenus 
anticus (superiorly and externally); longus colli (inferiorly and internally); 
rectus capitis anticus major (between and superiorly); vertebral artery and 
vein (between and inferiorly). Contents: Muscles — sternohyoid; sterno- 
thyroid. Arteries — common carotid (not strictly); inferior thyroid; vertebral. 
Veins — internal jugular. Nerves — pneumogastric; descending filaments from 
loop between descendens and communicans hypoglossi; recurrent laryngeal; 
sympathetic. Other Structures — larynx; trachea; thyroid gland; lymphatic 
glands. 

Posterior Triangle. — Boundaries : Anteriorly — posterior border of 
sternomastoid. Posteriorly — anterior border of trapezius. Superiorly — ■ 
occiput (apex). Inferiorly — superior border of clavicle (base). This triangle 
is subdivided into the occipital and subclavian triangles. 

Occipital Triangle. — Boundaries: Anteriorly — posterior border of 
sternomastoid. Posteriorly — anterior border of trapezius. Inferiorly — 
posterior belly of omohyoid. Coverings: integument; superficial fascia; 
platysma; deep fascia. Floor: splenius capitis; levator anguli scapulas; 
middle scalenus; posterior scalenus. Contents : Arteries — transversalis colli. 
Veins — transversalis colli. Nerves — spinal accessory; descending branches 
of cervical plexus. Other Structures — lymphatic glands. 

Subclavian Triangle. — Boundaries: — Posteriorly — posterior belly of 
omohyoid. Inferiorly — upper border of clavicle. Anteriorly — posterior 
border of sternomastoid (base). Coverings : — integument; superficial fascia; 
platysma; deep fascia; descending branches of cervical plexus. Floor :— 
first rib, first serration of serratus magnus. Contents : — Arteries — subclavian 
(third part); suprascapular; transversalis colli. Veins — subclavian (some- 
times); suprascapular; transversalis colli; external jugular; small vein from 
cephalic to external jugular. Nerves — brachial plexus, small nerve to sub- 
clavius. Other Structures — lymphatic glands. 

Lymphatic Glands of Head and Neck. — Consist of superficial and 
deep glands. (A) Superficial glands of head and neck : — Consist of 
transverse and vertical sets. (1) Transverse set of superficial glands: — 
Extend transversely from occiput along mastoid process, zygoma, and lower 
border of jaw, to symphysis menti, and comprise following groups; — (a) Oc- 
cipital or Suboccipital — below superior curved line of occipital bone, between 
skin and insertion of complexus muscle, (b) Posterior Auricular, or Sterno- 
mastoid — behind ear, between skin and insertion of sternomastoid. (c) 
Parotid — in front of ear, between skin and parotid gland, some being embedded 
within parotid gland, (d) Buccal — on surface of buccinator, between it 
and skin, (e) Submaxillary — in digastric triangle, between skin and mylo- 
hyoid and hyoglossus. (f) Suprahyoid — in middle line, between anterior 
bellies of digastric, between skin and mylohyoid. (2) Vertical set of super- 



REMOVAL OF LYMPHATIC GLANDS OF NECK. 151 

ficial glands (superficial cervical chain) : — (a) Anterior — in front of neck, 
between hyoid bone and sternum, and between skin and superficial muscles. 
(b) Middle (superficial cervical chain) — chiefly along external jugular vein, 
mainly in posterior triangle of neck, between platysma and deep cervical 
fascia, (c) Posterior — over trapezius, between it and skin. (B) Deep glands 
of head and neck : — Comprising those of head and neck. (1) Those of 
head : — Consisting of following groups: — (a) Lingual — on external surface of 
hvoglossus and geniohyoglossus. (b) Internal Maxillary — on lateral aspect 
of pharynx, behind buccinator muscle, (c) Posterior Pharyngeal — between 
posterior surface of pharynx and rectus capitis anticus major, near base of 
skull. (2) Those of neck : — Consisting of following sets; — (a) Superior set — 
along internal jugular vein, from base of skull to level of thyroid cartilage, 
(b) Inferior set — along internal jugular vein, from thyroid cartilage to near 
clavicle. 



REMOVAL OF LYMPHATIC GLANDS OF NECK. 

General Considerations. — In the case of diseased cervical glands, an 
operation may be undertaken — (1) for the removal of one or a few defined 
glands, in one or more of the regions of the neck, in which case a single or 
several incisions, more or less limited, are so placed as most readily and 
safely to expose the involved glands; — or (2) for the removal of glands widely, 
deeply, and indistinctly disseminated throughout the antero-lateral aspect 
of the neck, in which case one or more extensive incisions are necessary, 
both for the removal of the glands and in order to give room in which to 
safeguard important structures during their removal. Removal of dis- 
seminated cervical glands will be first described — and removal of isolated 
glands will be referred to under Comment. 

Indications for Removal of Cervical Lymphatic Glands. — Chronic 
tubercular adenitis (most frequently) ; acute non-tubercular suppurative 
adenitis; enlargement secondarily from neighboring malignant growths. 

Preparation. — Shaving of all hairy parts at site of and bordering upon 
field of operation. 

Position. — Patient supine; shoulders raised; neck resting over a support, 
to render it prominent; head so turned as to increase prominence, length, 
and width of neck, and in order to drag glands out from under protecting 
tissues. Surgeon on side of operation; assistant opposite. 

Landmarks. — The triangles of the neck. 

Instruments. — Scalpels; scissors, straight, curved, blunt and sharp; 
dissecting forceps; toothed forceps; artery-clamp forceps; blunt dissector; 
retractors; tenacula; grooved director; aneurism-needle; needles; needle- 
holder; sutures; ligatures; sterilized water on hand to flood neck in case of 
opening large vein in an inaccessible localitv. 

Incision. — Various forms of incision have been used, singly or combined. 
Where the entire antero-lateral aspect of the neck is to be exposed, a X-shaped 
incision (Fig. 101) may be used — BC extending from over the mastoid process 
to the interval between the sternal and clavicular attachment of the sterno- 
mastoid, passing down the middle of the sternomastoid or along its anterior 
border — BA extending transversely forward from the upper end of the oblique 
incision to the angle of the jaw, and thence along the lower border of the 
jaw to the symphysis — CD extending transversely outward along the upper 
border of the clavicle, as far toward the acromioclavicular articulation as 
necessarv. If only the anterior triangle of the neck be involved, the por- 



152 



OPERATIOXS UPON THE LYMPHATIC GLANDS AND VESSELS. 



tion ABC of the incision is alone used — if the posterior triangle, the portion 
BCD. 

Operation. — (i) Incise directly through skin, superficial fascia, platysma, 
and deep fascia — the diagonal portion of the X-shaped incision being first 
made; that is, the portion over the anterior border of the sternomastoid. 
Sever the external jugular vein between two ligatures. Branches of the 
superficialis colli nerve will be cut, but the auricularis magnus and occipitalis 
minor should be retracted backward, if exposed. This incision is carried 
down to and exposes the whole length of the sternomastoid muscle. (2) 
Carry the upper incision transverselv downward to the angle of the jaw, 




N, 



Fig. 1 01. —Incisions for Exposing Lymphatic Glands of Cervical Rf.c.ion :—BC, Line over 
anterior border of sternomastoid, from mastoid process to interval between sternal and clavicular 
origins of sternomastoid ; BA, Line from mastoid process to angle of jaw, and thence forward along 
its lower border; CD, Line from sternoclavicular articulation outward along upper border of clavicle. 
Anterior triangle of neck is exposed by raising flap ABC; Posterior triangle, by raising flap BCD ; 
Entire antero-lateral aspect of neck, by raising both flaps. Following incisions may be used for 
removing isolated groups of glands ; EF, Incision parallel with anterior border of sternomastoid ; 
GH, parallel with posterior border ; IJ, Transverse oblique in upper part of neck ; KL, Transverse 
oblique in lower part of neck. 



and then forward along the lower border of the inferior maxilla toward the 
symphysis, passing through the skin, superficial fascia, platysma, and deep 
fascia — and exposing, without injury, the parotid gland, facial nerve, tribu- 
taries of temporomaxillary vein, facial artery and vein, submaxillary and 
submental glands. The facial artery and vein may be divided between two 
ligatures, if necessary. (3) The lower incision is now carried transversely 
along the upper border of the clavicle, as far toward its outer end as necessary 
— passing through skin, superficial fascia, platysma, and deep fascia — 
dividing some of the descending superficial branches of the cervical plexus 
and a few minor vessels. (4) Having now completed these three incisions, 



REMOVAL OF LYMPHATIC GLANDS OF NECK. 153 

two triangular flaps are carefully dissected up and turned aside — an anterior 
flap (ABC), having the same boundaries as the anterior triangle of the neck, 
is turned forward, hinging on the anterior median line of the neck — and a 
posterior flap (BCD), having the same boundaries as the posterior triangle 
of the neck, is turned backward, hinging on the anterior margin of the tra- 
pezius (or on a line posterior to that, if the lower transverse incision have 
been extended posteriorly to the acromioclavicular articulation). Thus, 
the superficial parts having been turned aside, the entire antero-lateral quadri- 
lateral surface of the neck is exposed on a plane with the important structures 
and in easy access to those structures. (5) All glands are now dissected out, 
together with their surrounding connective tissue — being sought in the locali- 
ties indicated in the above summary (see Lymphatic Glands of Head and 
Neck, page 150) — guarding, at the same time, the important anatomical 
structures enumerated under Surgical Anatomy of the Triangles of the Xeck. 
(6) If avoidable, the sternomastoid should not be cut — it generallv being 
possible, in such a free exposure, to retract it alternately well forward and 
backward in order to remove the glands partly or entirely covered In - it, 
slightly flexing the chin on the sternum to lessen tension. Where, however, 
it proves a barrier to thorough and safe work, it should be unhesitatingly 
severed — the emergence of the spinal accessory nerve from its posterior 
border being exposed, and the muscle divided transversely below the nerve 
The upper end of the muscle is then turned upward and backward with 
the uninjured nerve, and the lower end downward and forward — and the 
important structures beneath it thus easily brought to view. (7) In com- 
pleting the operation, the cut ends of the sternomastoid should be carefully 
sutured with interrupted buried catgut sutures. The flaps are now turned 
back into place and sutured throughout — the flaps being sutured to each 
other first, then along the superior transverse line, and, last, along the inferior 
transverse line — the wound being closed throughout with silkworm-gut or 
silk — and firm pressure, to occlude dead spaces, made in the dressing. The 
neck and head are steadied in some form of retentive apparatus until union 
has occurred. 

Removal of Isolated Lymphatic Glands of the Neck. — These isolated 
glands will belong to one of the groups of superficial or deep glands given, 
with their relations, upon a preceding page. The position, direction, and 
extent of the incision for their exposure will be determined by the special 
group of glands involved and the extent of the involvement — the general 
rule being that the incision is so placed as to reach the site most readily and 
with greatest safety to neighboring structures — and mav be a single vertical, 
transverse, or oblique straight incision, making an opening whose lips have 
to be retracted to expose the parts; — or a combination of these; — or a curved 
incision, thereby forming a flap, which is temporarily turned back. The 
two most generally used forms of incision, however, are those which are 
more or less parallel with one of the borders of the sternomastoid (Fig. 101, 
EF or GH) — or more or less parallel with the natural obliquely transverse 
crease crossing the neck about on a level with the hyoid bone, in the cleavage 
line of the skin (Fig. 101, IJ or KL). The incision may be placed over the 
submaxillary, superior carotid, or inferior carotid triangle, of the anterior 
triangle of the neck, or over the occipital or subclavian triangle, of the posterior 
triangle — or over the posterior aspect of the neck, between the anterior border 
of the trapezius and the posterior median line, and between the superior 
border of the scapula — or may involve several triangles. 

Comment. — (i) Great care is necessary in removing glands from thin- 



154 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 

walled veins. Should a vein be wounded, the opening should be caught up 
instantly and laterally ligated, if the wound be appropriate, or sutured, or 
even transversely ligated. If so situated that closure cannot be immediately 
made, the part should be flooded with water, so that water stands over the 
open vein, to prevent the drawing-in of air until the vein can be secured. 
(2) The important nerves are to be particularly guarded. (3) The arteries 
and arterial hemorrhage give far less concern than the veins and venous 
hemorrhage. (4) It is better to dissect the glands out in masses or chains, 
together with their adherent connective tissue — invisible, impalpable glands 
being thus more thoroughly removed. (5) Glands should be removed with 
their capsules intact. (6) The sternohyoid and omohyoid may also be divided 
and subsequently sutured. (7) All bleeding should be immediately con- 
trolled as encountered, and ligated as soon as convenient. 



SURGICAL ANATOMY OF AXILLARY REGION. 

Description. — The axilla is a pyramidal space between the upper lateral 
wall of thorax and inner wall of arm — its apex corresponding with interval 
between first rib on inner side, clavicle in front, and upper edge of scapula 
behind; — its base, broad at chest and narrow at arm, is composed of skin 
and dense fascia, extending between inferior border of pectoralis major in 
front, and inferior border of latissimus dorsi behind. 

Boundaries. — Anteriorly — pectoralis major (throughout) ; pectoralis 
minor (its center). Posteriorly — subscapulars (above); teres major and 
latissimus dorsi (below). Internally — first to fourth ribs; first to third 
intercostal muscles; serratus magnus. Externally — humerus; coracobrachi- 
al ; biceps. 

Contents. — Arteries : — axillary (along external wall, nearer anterior than 
posterior boundary); superior thoracic; acromial thoracic; long thoracic; 
alar thoracic; subscapular; anterior circumflex; posterior circumflex. Veins : 
— axillary (to inner side of axillary artery) ; receiving venae comites of brachial 
artery and tributaries of branches of axillary artery. Nerves: — brachial 
plexus lies to outer side of first part of axillary artery; — the second part of 
axillary artery has the outer, inner, and posterior cords of plexus in the rela- 
tions expressed by their names; — the third part of the artery has, anteriorly, 
inner head of median nerve; posteriorly, musculospiral and circumflex; 
externally, median, musculo-cutaneous; internally, ulnar, internal cutaneous, 
lesser internal cutaneous. Posterior thoracic (on serratus magnus). In- 
tercosto-humeral. External and internal anterior thoracic, crossing in front 
and behind axillary artery respectively. Glands : — see below. 

Axillary Lymphatic Glands.— Are arranged in four groups: (a) Axillary 
glands proper — median set; three or four in number; along axillary artery 
and vein, (b) Pectoral glands; inner or anterior set; four or five in number; 
along long thoracic artery, below great pectoral muscles and on serratus 
magnus. (c) Subscapular glands — external or posterior set; two in number; 
along subscapular artery, under latissimus dorsi. (d) Subclavian or infra- 
clavicular — superior set; two in number; near cephalic vein; just below clavicle 
in fossa under pectoralis major and deltoid, upon costocoracoid membrane. 

Axillary Lymphatic Trunk. — Efferent trunk from above sets of glands 
— runs upward along subclavian vein — emptying into thoracic duct on left, 
and into right lymphatic duct on right. 



REMOVAL OF AXILLARY LYMPHATIC GLANDS. 



155 



REMOVAL OF AXILLARY LYMPHATIC GLANDS. 

Description. — The removal of the axillary glands is done, in the majority 
of cases, in connection with the removal of neighboring malignant growths, 
especially those involving the breast — and, in such cases, the incision for 
exposing the axillary region is merely a prolongation into the axilla of the 
incision for the original operation. The steps, therefore, of the operation 
for the removal of these glands will be found sufficiently described under 
the operations for the radical removal of the breast (pages 738 to 744). Where 
it is planned to remove enlarged ax- 
illary glands alone and as a distinct 
operation, the incision is placed 
over the involved glands (Fig. 102). 



SURGICAL ANATOMY OF 
SCARPA'S TRIANGLE. 

Description. — A triangular 
area just below fold of groin. 

Boundaries. — Base (above) ; 
Poupart's ligament. Externally; 
sartorius. Internally; adductor 
longus. Apex (below) ; junction of 
sartorius and adductor longus. 

Roof. — Skin; superficial fascia; 
fascia lata. 

Floor. — (From without in- 
ward.) Iliacus; psoas; pectineus; 
adductor brevis; adductor longus. 

Contents. — Arteries; common 
femoral (from middle of base to 
apex); superior epigastric; superfi- 
cial circumflex iliac; superficial ex- 
ternal pudic; deep external pudic; 
profunda femoris. Veins; femoral 
(to inner side of artery) ; profunda 
femoris; tributaries of branches of 

femoral; internal saphenous. Fig. io 2 .-Incision for Exposing Axillary 

Nerves; anterior crural (to outer Lymphatic Glands:— Passing between biceps 

Side of arterv) ; crural branch of and pectoral muscles, in front, and the scapular 

, ' ' . muscles, posteriorly; to which may be added one 

gemtocrural; external cutaneous. or more modifying incisions, as necessitated by 

Lymphatics; superficial and deep the special case, 
glands. 

Inguinal Lymphatic Glands. — Consist of two following sets; (1) Super- 
ficial Glands ; Oblique or Inguinal Set — along Poupart's ligament, upon 
fascia lata. Vertical or Saphenous Set — around saphenous opening and upon 
fascia lata. (2) Deep Glands ; along upper part of femoral vessels, one or 
more being within femoral canal. 




156 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 



REMOVAL OF INGUINAL LYMPHATIC GLANDS. 

Description. — The operation will differ according to site and amount 
of glandular involvement — and the lines of incision are given accordingly. 
Indications. — Glands enlarged or broken down as a result of venereal 
disease; tubercular glands; simple, chronic, and suppurative adenitis; malig- 
nant involvement. 

Preparation. — Groin shaved. 

Position. — As for ligation of femoral artery at base of Scarpa's triangle 

(page 95). 

Landmarks. — Given under Sur- 
gical Anatomy of Scarpa's Triangle. 
Instruments. — As for removal 
of cervical glands (page 151). 

Incisions.— (1) Where the ob- 
lique (superficial) set of glands are 
involved — an incision may be made 
parallel with and just below Pou- 
part's ligament, with its center over 
the enlarged glands (Fig. 103, B); 
or just above Poupart's ligament 
(Fig. 103, A). (2) Where the 
vertical (superficial and deep) sets 
are involved — the incision is made 
along the course of the femoral 
artery, with its center over the 
enlarged glands (Fig. 103, B). (See 
ligation of common femoral at base 
of Scarpa's triangle, page 93.) (3) 
Where all three sets are involved — 
the incision may be a combination of 
the above two, being somewhat 
T->haped. 

Operation. — Divide skin and 
superficial fascia in the direction or 
directions indicated above. The 
superficial vessels encountered are 
ligated. The superficial glands 
(oblique and vertical sets) will be 
found upon the fascia lata, in the positions indicated. To reach the deep 
glands (lying along the great vessels) the fascia lata is incised in the line of the 
femoral artery (as for ligation of that artery). Important structures are to be 
avoided and the glands sought along the course of the artery and vein. The 
general principles mentioned under the removal of cervical lymphatic glands 
are applicable here — and elsewhere, wherever glandular tissue is removed. 




Fig. 103. — Incisions for Exposing 
Inguinal Lymphatic Glands: — A, Oblique 
incisions just below and parallel with Pou- 
part's ligament, for oblique superficial set 
of glands; B, Vertical incision over femoral 
artery, for vertical superficial and deep sets. 
A T-shaped incision may be made by uniting 
these, where all three sets are involved. 



CHAPTER IV. 

OPERATIONS UPON THE NERVES, PLEXUSES, 
AND GANGLIA. 

Note. — The operations which may be performed upon Nerves, Plexuses, 
and Ganglia will be first described — and then the operations for the exposure 
of the more important nerves, plexuses, and ganglia will be given. Having 
exposed a nerve, any of the operations about to be described may be applied 
to it, as indicated. 

NEUROTOMY. 

Description. — Section of a nerve. Neurotomy may be transverse (e. g., 
as when performed for neuralgia of a sensory nerve, or spasm of a motor 
nerve) ;— or longitudinal (e.g., as done in some cases of neurorrhaphy and 
neuroplasty). 

Indications. — Neuralgia of sensory nerves; spasm of motor nerves; 
preliminary to neurorrhaphy or neuroplasty. 

Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
— Determined by the special nerve involved. 




Fig. 104. — Neurotomy of Supraorbital Nerve. 



Operation. — Having exposed and isolated the individual nerve, it is 
lifted from its bed by forceps and divided with a scalpel or scissors. The 
cut ends are allowed to fall back into place — or, better, should be so dropped 
back into the wound as to make re-union unlikely. The wound is closed as 
usual. No special after-treatment is carried out (Fig. 104). 

Comment. — Chiefly applicable to smaller sensory nerves — and, rarely, 
smaller motor nerves. Not generally successful in neuralgias. 

i57 



158 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



NEURECTOMY. 

Description. — Excision of a nerve. Neurectomy may be partial or com- 
plete. As ordinarily performed, only a small part of the length of the nerve 
is removed. 

Preparation— Position — Landmarks — Surgical Anatomy— Incision. 
— Determined by the special nerve. 

Indications. — Neuralgia of sensory nerves; spasm of motor nerves. 




Fig. 105. — Neurectomy of Supraorbital Nerve. 

Operation. — The nerve having been exposed and brought well into 
the field, is lifted out of its bed with forceps — and from 2 to 3 cm. (1 to 1^ 
inches) of its trunk is excised with scalpel (preferable to scissors, which partly 
crush). The ends are then allowed to drop back into position — and the 
wound is closed (Fig. 105). 

Comment. — Total excision is most frequently done by avulsion (page 159). 



NEURECTASY. 

Description. — Nerve-stretching. 

Indications. — Neuralgia of sensory and spasm of motor nerves. 

Preparation — Position — Landmarks — Surgical Anatomy — Incision. 

- — Determined by the nerve operated upon. 

Operation. — The nerve is freely exposed and separated by blunt dis- 
section sufficiently for manipulation. Small nerves are stretched by means 
of a nerve-hook inserted beneath them. Large nerves are stretched by being 
grasped between thumb and finger — the nerve is steadily and evenly pulled 
from its center for about five minutes — then from its periphery for about 
five minutes. The extremes of force employed may be represented by a 
pull of a half-pound for the supraorbital — and from thirty to sixty pounds 
(according to the judgment of the operator) for the sciatic. The manipu- 
lation is done with as limited disturbance to the surrounding structures as 
possible. After the stretching, the nerve is dropped back into place and the 
incision closed. In the after-treatment, the part should be immobilized until 
union of the wound occurs. Temporary paralyses of motion and sensation 



NERVE-AVULSION. 



J 59 



are to be expected (Fig. 106). The breaking strain of the principal nerves 
of the body has been given by Nombetta as the following: — 

Great sciatic 183 pounds 

Internal popliteal 114 

Anterior crural 83 

Median crural 83 

Ulnar and radial 59 

Brachial plexus in the neck 48-63 

Brachial plexus in the axilla 35~8i 







Fig. 106. — Neurectasy of Infraorbital Nerve. 

Comment. — Sensory nerves seem more dulled by traction in a direction 
away from the cord — motor nerves more dulled by traction toward the cord. 



• 




Fig. 107.— Nerve-avulsion of Infraorbital. 

NERVE-AVULSION. 

Description. — The tearing away of a nerve from its central and peripheral 
connections. 

Indications. — Neuralgia. Chiefly used upon branches of the fifth nerve. 

Preparation— Position— Landmarks— Surgical Anatomy— Incision. 
— Determined by the special nerve. 



160 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Operation. — Having exposed the nerve involved, it is grasped by catch- 
forceps (firmly, but not strong enough to crush and break it) — and then 
slowly wound around the forceps (by twisting the latter between the fingers) 
— until the nerve is torn away from its connections, both proximally and 
distallv. Branches of the nerve are also sometimes avulsed, to a greater or 
less extent along with the main trunk — as well as a part or the whole of a 
ganglion. The nerve may, also, be partly cut — either distallv (generally) 
or peripherally. The wound is closed throughout, in the usual manner 
(Fig. 107). 

NEURORRHAPHY. 

Description. — Suturing of nerve which has been partially or entirely 
divided. Neurorrhaphy may be primary, or immediate, where the nerve 
is sutured at once, — or secondary, where the suturing is done subsequent 
to repair of injury. 

Indications. — Repair of injury to nerve. Neuroplasty. 

Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
— Determined by the nerve involved. 

Operation of Primary, or Immediate, Neurorrhaphy. — The severed 
nerve-ends are exposed in the wound and brought well within reach. See 
if they be cleanly cut. If not, gently grasp them with forceps and cut them 
cleanlv, and preferably transversely, with a sharp knife, with a minimum 
sacrifice of nerve-tissue. The ends are brought and held in apposition, in 
their normal relations, anterior aspect to anterior aspect, and the like. If 





Figs. 108-112. — Methods of Nerve-suturing: — I. — A B, C, Sutures passing through entire 
thickness of nerve and sheath; D, E, Sutures passing through nerve-sheath only. 

the ends cannot be approximated, flex or extend the limb to increase the 
length, or stretch both ends gently (preferably grasping them with the fingers). 
It is desirable that there should be no tension upon the sutures. The junction 
is made with a fine cambric needle threaded with fine chromic catgut and 
held in a needle-holder. One of several methods of suturing may be adopted; 
— (a) The sutures may be passed entirely through the sheath and nerve, in 
two or more directions, and about 3 mm. (i inch) from the ends. The 
needle passes from before backward through the entire thickness of the 
proximal end — then similarly through the distal end, from behind forward— 



NEURORRHAPHY. 



161 



and the suture is tied lightly, so as not to have tension. A second suture may 
be applied antero-posteriorly, or laterally — and as many as seem needed 
accurately to coapt the ends. This is the most general method of nerve- 
suturing (Figs. 108-112, A, B, C). (b) Sutures may be passed through the 





Figs. 113-117. — Methods or Nerve-suturing: — II. — A, B, Sutures passing through 
sheath and part of nerve; C, Sutures through sheath, reinforced by relaxation-suture through 
entire nerve; D, Nerve cut obliquely and united by suture through sheath and part of nerve; 
E, Same with relaxation-suture. 

nerve-sheath alone, encircling the nerve proper. This is the preferable 
operation — but is possible only in. large nerves (Figs, in, 112, D, E). (c) 
Part of the sutures may pass through the nerve and sheath (as in a) — and 
part through the sheath only (as in b) (Figs. 113, 114, 115, A, B, C). (d) 





Figs. 118-121. — Methods of Nerve-suturixg : — III. — A, Reinforcing through-and- 
through suture by lateral suture through loops of first suture; B, C, D, Various methods of 
union by approximation of lateral aspects of nerve, after freshening. 

After paring the larger end, it may be split down its center for about 1.3 cm. 
{\ inch) — the smaller end may be beveled on two sides and sutured between 
the lips of the split end (Fig." 122, A), (e) One end may be beveled on its 
upper surface, the other on its lower surface — the two freshened surfaces 
are then placed in contact and sutured through and through (Figs. 116 and 



162 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



117, D, E). This requires a greater length of nerve than some of the other 
methods. Other methods are shown in Figs. 118 to 121 and 123, B, and 124, 
C. Having completed the union of the nerve-ends, the wound is sutured and 
the limb immobilized so as to minimize tension for about ten days — the part 
is then gently massaged daily and the splint reapplied between times and not 
removed for about six weeks. Primary union is particularly to be sought. The 
restraining splint should be such as will hold the part so that the nerve will be 
relaxed. 

Operation of Secondary Neurorrhaphy. — Having applied Esmarch's 
bandage, one may cut directly down upon the supposed site of the nerve ends. 
It is better, however, deliberately to incise for and expose both proximal 
and distal nerve-trunks, above and below the involvement, on anatomical 
grounds. Much difficulty may be experienced in finding the nerve-ends, 
unless traced down and upward, as the case may be, from the nerve-trunks. 
The proximal end is easier to find, and apt to be bulbous and sensitive. The 
distal end is apt to be atrophied. Sufficient freeing of the nerve-ends to 
enable them to meet is necessary. While in primary suturing the severed 

ends may or may not 
require trimming before 
suturing, in secondary 
suturing they are, in ad- 
dition to being freed 
from connective tissue, 
always to be excised. 
Having identified the 
nerve-ends, dissect away 
all intervening fibrous 
tissue. With a sharp 
knife cut away trans- 
versely the proximal 
end until healthy nerve 
tissue is reached. In 
the case of the distal 
end, simply cut away 
enough of the upper 
end to afford good ap- 
proximation (for degen- 
erative processes will 
have extended far down 
this end under any cir- 
cumstances). If the ends can now be made to meet without too much ten- 
sion, they are sutured together by one of the methods described under primary 
neurorrhaphy. If greater length be necessary, as is almost invariably the 
case, it may generally be gotten by first carefully stretching the ends — after 
which they are united by suture. If sufficient length cannot be thus secured, 
neuroplasty must be done (page 163). Following secondary neurorrhaphy 
the wound is closed, the limb splinted, and the same after-treatment carried 
on as after the primary operation — although results are not to be expected 
so soon. Restoration of function may require from one to two years. 

Comment. — Where stretching is resorted to to gain length in secondary 
suturing, it should be applied before excising the nerve-ends — traction being 
made upon the nerve-ends themselves, which are afterward removed. And 
if tension be too great upon the sutured ends, relaxation-sutures may be 
applied above and below the line of finer approximation sutures. 




«f 




Figs. 122-124. — Less Usual Methods of Nerve- 
suturing: — IV. — A, Suturing of beveled end between lips of 
split end; B, C, Method of uniting sound upper and lower 
portions of nerve by splitting and suturing contracted portion. 



NEUROPLASTY. 



163 



NEUROPLASTY. 

Description. — The union of severed nerve-ends by processes of plastic 
elongation of the nerve itself, — or by the interposition of nerve or other 





Figs. 125-128. — Neuroplasty : — I. — A, B, Union by splitting both ends of nerve and uniting 
split ends end-to-end; C, D, Same, with split ends united laterally. 

material — in cases where the loss of nerve-substance is so great that the 
severed ends cannot be brought and held together by the ordinary methods 






Figs. 129-132. — Neuroplasty: — II. — A, Splitting one end, with union of lateral aspect 
of split end to lateral aspect of opposite entire end freshened laterally; B, Same, with union 
end-to-end; C, D, Same as in B, in case of bulbous ends. 



164 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 




— Neitroplasty: — III. — A, B, 
Doubly splitting both ends, with union of split ends 
end-to-end; C, Interpolation of section of nerve. 



of suturing. The object sought in the latter cases is the supplying of a sub- 
stance between the cut ends along which the nerve-fibers may grow from 

the proximal to the distal end 
(as the tendrils of a vine grow 
along a trellis). The operations 
of nerve-anastomosis, nerve- 
grafting, and nerve-implanta- 
tion are also instances of neuro- 
plasty. 

Indications.— Where, in 
primary operations, consider- 
able nerve-substance has been 
destroyed by the cause of the 
injury — or, in secondary oper- 
ations, the retraction of the 
severed ends has been very 
great — so that by no other 
means can the ends of the 
nerves be brought and kept 
together. 

Preparation — Position — 
Landmarks — Surgical Anat- 
omy — Incision. — Determined 
by the special operation. 

Operation. — Having exposed 
and isolated the severed ends, 

and, in the case of secondary operations, freed them from connective tissue 

and freshened them by partial excision, one of the following means of bringing 

and holding the ends in contact is 

resorted to: — (a) At points as far from 

the ends of the nerves as indicated by 

the length of the intervening space to be 

filled, divide each nerve half-way, trans- 
versely — split each end back to within 

about 6 mm. (| inch) of its end — 

bend the two cut portions toward each 

other — and suture them end to end, or 

laterally (Figs. 125-128, A, B, C, D). 

In filling smaller gaps, one trunk only 

may be split — bent back to the other 

end — and both freshened and sutured 

(Figs. 129 and 130, A, B). (b) Sec- 
tions of nerves from a freshly amputated 

human limb, or from the lower animals, 

may be interposed in the gap and 

sutured at both ends by one of the 

methods given under neurorrhaphy. 

This interposed part does not grow, 

but only serves the role of a trellis 

(Fig. 135, C). (c) A solid cylinder 

of decalcified bone may be interposed 

and sutured to the ends of the nerves, (d) Strands of fine catgut may be 

made to bridge the interval, as a guide to the new nerve-fibers (Fig. 136, A). 



C2E^ 



) 





Figs. 136-138. — Neuroplasty : — IV. 
— A, Union by strands of gut alone; B, C, 
Same, reinforced with decalcified bone 
cylinder. 



NERVE-ANASTOMOSIS; NERVE-GRAFTING; NERVE-IMPLANTATION. 165 

(e) The proximal and distal ends of the nerve may be enclosed in a hollow 
cylinder of decalcified bone (Figs. 137 and 138, B, C). (f) Proceed as in 
Fig. 133, A — then shift the cut ends laterally, and approximate as shown in 
Fig. 134, B. (g) Combine methods (d) and (e) — the combined method of 
bridging with catgut and enclosure in decalcified bone tube. One end of the 
catgut bridge is slipped through the tube, sutured to the other end, and drawn 
back within the tube (Figs. 136 and 138, B, C). (h) Shortening of the limb, 
by resection of its bone or bones, to allow of approximation of the ends of 
the nerve. (The musculospiral has been thus successfully treated.) Of 
the above methods, method (a) is the one most generally used. Having 
completed the neuroplastic operation, the wound is closed and the part immo- 
bilized in a position to relax the nerve. 



NERVE- ANASTOMOSIS; NERVE-GRAFTING; NERVE-IMPLANTATION. 

Description. — The grafting of any portion of an injured nerve into the 
trunk of a neighboring nerve. In the case of a divided and retracted nerve, the 
severed upper end is grafted into the intact nerve at a point opposite its level, 




<3S23| 



D 

Figs. 139-142. — Nerve-grafting: — I. — A, B, Engrafting of freshened lower end of 
divided median nerve (for instance) upon intact ulnar nerve; C, D, Engrafting of freshened 
upper and lower ends of divided median nerve upon intact ulnar nerve. 

above — and the severed lower end grafted into the intact trunk opposite its 
level, below — that is, at points where they can be conveniently brought into 
contact with the sound nerve. The object sought is to switch the interrupted 
nerve-stream, or nerve-impulse, from the proximal end of the cut nerve into 
the neighboring sound nerve — thence to have it conveyed along this used 
nerve down to the point where the distal end of the cut nerve is sutured to the 
utilized nerve — and thence returned to the original nerve and transmitted 
along the distal portion of the cut nerve to its final distribution, as though no 
interruption to its normal course and transmission had occurred. An illus- 
tration would be a divided median nerve and an intact ulnar nerve — where 
the upper end of the median nerve is sutured to the upper part of the ulnar — 



166 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

and the lower end of the median to the lower part of the ulnar (Figs. 141 
and 142, C, D). The object finally sought is to have nerve-fibrils grow 
down this nerve from the proximal cut end to the distal cut end. The method 
is of limited application, because of the necessity of finding large nerves in 
close proximity — the upper extremity being about the only locality in which 
the method can be utilized (Figs. 143 and 144), or the lower end only may be 
grafted upon the sound nerve — the impulse from the latter passing into the 
impaired nerve and going on to its distribution (Fig. 143, A and B). 

Preparation— Position — Landmarks — Surgical Anatomy — Incision. 
— Determined by the individual operation. 

Operation. — Expose, isolate, and excise the proximal and distal ends 
of the severed nerve, supposing it to be a secondary case. Also through 





Figs. 143 and 144. — Nerve-grafting: — II. — A (to left), Showing ulnar and median 
nerves divided at different heights; B (to right), Union of upper end of median to lower end of 
ulnar; — followed by engrafting of upper end of ulnar and lower end of median into this new 
trunk. 

the original incision, expose the neighboring nerve upon which the grafting 
or implantation is to be made. By means of curved scissors, remove a limited 
portion of its sheath, on the lateral aspect of the nerve, at the sites where 
the upper and lower severed nerve-ends are to be grafted. The obliquely 



NERVE- ANASTOMOSIS; NERVE-GRAFTING; NERVE-IMPLANTATION. 167 

or transversely divided ends of the involved nerve are to be sutured to the 
denuded lateral aspect of the intact nerve, above and below, by fine chromic 





B C D 

Figs. 145, 146, 147, and 148. — Nerve-graftixg: — III. — A, The darker, smaller nerve 
has lost all function, — B, Is divided transversely and its distal end sutured into the sound nerve. 
G, The darker nerve has lost all function, — D, Is divided and sutured to the split portion of the 
sound nerve. 

sutures passing through the sheath of the nerve-ends, on the one hand, 
and through the sheath and part of the thickness of the intact nerve at the 





Figs. 149, 150, 151, and 152. — Nerve-graftixg: — IV. — E, The darker, smaller nerve has 
retained part of its function, — F, Is split and its split end sutured to the split end of the sound 
nerve. G, The darker nerve has retained part of its function, — H, Is divided transversely, and 
its proximal end sutured to the distal split portion of the sound nerve, while its distal end is 
sutured to the proximal split portion of the sound nerve. 

bared sites, on the other hand. Having completed the nerve-suturing, if 
the neighboring parts have been disarranged, these should be rearranged — 
by buried catgut sutures, if necessary. The wound is then closed throughout. 



168 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

The part should be immobilized in a position of relaxation of nerve-tension 
until union has occurred — and subsequently treated as described under 
neurorrhaphy. It sometimes happens that an adjacent nerve has, through 
degenerative changes, sustained a total or partial loss of function. Where 
the loss is complete (Fig. 145, A), the involved nerve is divided transversely 
and its distal end sutured laterally to the adjacent sound nerve (Fig. 146, B); — 
or the distal end may be sutured end-to-end to split portion of the sound nerve 
(Figs. 147 and 148, C and D). Where the loss of function in the involved 
nerve is not complete, a cross-anastomosis may be done, thus preserving all 
of each nerve, — that is, both nerves may be split, and the split portions sutured, 
leaving the main trunks continuous (Figs. 149 and 150, E and F); — or the 
involved nerve may be divided transversely and the sound nerve split longi- 
tudinally in both directions, after which the proximal end of the impaired nerve 
is sutured to the distal split portion of the sound nerve, and the distal end of 
the impaired nerve is sutured to the proximal split portion of the sound nerve 
(Figs. 151 and 152, G and H). 

Comment. — (i) The severed distal end of the involved nerve is sometimes 
bevelled and implanted within the incised substance of the sound nerve 
(Fig. 153). It may happen, in extensive injuries, that the lower portion of 
one nerve is destroyed, and -the upper end, or ends, of one or two adjacent 




Fig. 153. — Implantation of Bevelled End of Divided Nerve into Longitudinal 
Slit in Sound Nerve. 

Fig. 154. — Anastomosis of Divided Distal Ends of Two Nerves whose Proximal 
Portions have been Destroyed, into Proximal Trunk of Adjacent Nerve whose Distal 
Portion has been Destroyed. 

nerves. In such unusual cases, and in the rare localities where such a pro- 
cedure is possible, the divided distal ends of the latter may be sutured into 
the transversely divided proximal end of the former (Fig. 154). (2) It 
seems to make no difference whether a sensory nerve be grafted to a motor 
or to a mixed nerve— or vice versa. 



INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 169 

NEUROLYSIS, OR AN OPERATION FOR RELIEF OF NERVE COM- 
PRESSED BY BONY OR FIBROUS CICATRICIAL TISSUE OR BY 
ADHESIONS. 

Description. — Nerves are sometimes involved and pressed upon in the 
processes of repair following injury of bones and soft parts, or in the processes 
of disease, or by adhesions, and eventually become so firmly compressed as 
to have their function impaired — in which case an operation to free them for 
pressure is indicated. 

Position — Landmarks — Incision. — Dependent upon nerve involved. 

Operation. — The steps of the operation will be determined by the position 
and nature of the compression. Where fibrous cicatricial tissue surrounds 
the nerve, the mass is to be exposed by dissection — the nerve is to be isolated 
either above or below the mass and is to be followed through it and dissected 
out from it. The cause of compression, as far as possible, is to be removed, 
so as to avoid a recurrence. Where a bony callus surrounds the nerve, this 
is to be reached by the safest route through the muscular planes — the nerve 
being similarly isolated above and below the mass — and freed through it. 
It is often necessary to chisel away as much of the callus as imprisons the 
nerve — and in order to render a recurrence of compression unlikely. The 
wound is closed as usual. Cargile membrane has been used to prevent 
re-adhesion. 

Comment. — Nerves may be compressed by growing tumors — their relief 
being determined by the treatment adopted for the tumor, or nerves may be 
compressed by their thickened sheaths, which require longitudinal incision. 

INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 

OPERATION OF MAT AS AND CRILE. 

Description. — -The injection of a sterilized anesthetic solution directly 
into a nerve-trunk. The injection may be made at the site of the proposed 
operation, or above the site. 

Indications. — To produce anesthesia in the region supplied by the nerve, 
for the purpose of major or minor operations. Especially indicated in those 
portions of the body in which nerve-trunks may be isolated, — and in those 
cases in which general anesthesia is contraindicated. 

Position — Landmarks— Incision. — Determined by the special operation. 

Nature of the Anesthetic Solutions. — These have been of various con- 
stitutions and percentages — there being no recognized standard solution 
universally employed in this comparatively new field of surgery. Sterilized 
solutions of cocain, of eucain B, of nirvanin, of Schleich's solution, and others, 
have been used. Almost any suitable syringe may be employed, though a 
special instrument is more appropriate. Matas (whose writing upon local 
anesthesia this article largely follows) uses from 5 to 40 min. (according 
to the size of the nerve) of Schleich's solution No. 1. (One tablet of Schleich 
No. 1 dissolved in 100 minims of water, represents -5^ part of cocain hydro- 
chlorid, 4 0V0 P art of morphin hydrochlorid, and -5-^-,- part of sodium chlorid.) 

Operation. — The anesthetic fluid may be injected at the site of operation 
or above it; — (a) Where the Injection is made into the Nerve-trunk above 
the site of Operation — the anesthesia being produced in the region supplied 
by the nerve: — (Suppose the injection be made into the sciatic nerve, .for 
amputation of the leg); To prepare the way for the incision, anesthetize the 
skin by intradermal infiltration — and the connective tissue by subdermal 



170 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

(subcutaneous) infiltration — both with the Schleich solution. Expose the 
sciatic nerve above the bifurcation into internal and external popliteal and 
isolate it sufficiently for manipulation. Insert the needle of the syringe 
through the sheath of the nerve and into and among its fibers — and slowly 
inject the anesthetizing fluid (the amount determined by the nature of the 
solution and size of the nerve) until the entire extent of a transverse section 
of the nerve has been infiltrated or "blocked" (Fig. 155). If this single 
injection be considered sufficient to last throughout the operation, the wound 
may be at once closed — otherwise it is temporarily packed with gauze. The 
limb is elevated and exsanguinated by gravity. A circular constrictor is 
applied above the site at which the nerve was infiltrated. Within a few 
minutes of the infiltration, the distal regions supplied by the nerve will be 




Fig. 155. — Intraneural Infiltration for Regional Anesthesia: — The great sciatic nerve 

being here infiltrated. 

completely anesthetic, and any operation may be performed thereon, as long 
as the constrictor remains in situ, (b) Where Infiltration is made into 
Nerve-trunks as exposed in the course of an Operation: — Anesthetize the skin 
by intradermal infiltration, and the connective tissue by subdermal infiltration. 
As each nerve is exposed it is isolated, taken up, and infiltrated, as in the 
above method. Where the case is a limb, a circular constrictor is used as 
above. Where the region is such an one as is involved in the radical operation 
for inguinal hernia, no arrest of circulation is attempted. In this method 
the anesthesia is complete not only at the site infiltrated, but in the regions 
supplied by the infiltrated nerves — but lasts a shorter time, unless the infiltra- 
tion be repeated, than where a constrictor can be applied. 

Comment. — If the site of operation be supplied entirely by one nerve, 
that nerve alone need be infiltrated, at some convenient point proximal to the 
site of intended operation. If the site of operation, however, be supplied by 



PARANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 171 

several nerves, each has to be separately infiltrated; — for example, in the 
operation of amputation of the leg described above, if the operation is to be 
above the level of the tuberosity of the tibia, the anterior crural nerve is to be 
also injected, — if below that level, the long saphenous nerve is to be injected 
instead of the anterior crural — the sciatic being, of course, infiltrated in both 
instances. The entire upper limb can be anesthetized by infiltrating the 
brachial plexus above the clavicle. 

PARANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 

MATAS' METHOD. 

Description. — The injection of a sterilized anesthetic solution into the 
tissues immediately surrounding a nerve-trunk, so planned as to envelop the 
nerve as closely as possible in an anesthetic atmosphere, as it were. 

Indications. — To produce anesthesia in the region of the infiltration and 
as far beyond as the solution is diffused. 

Position — Landmarks. — Determined by the special operation. 

Operation. — Without making any incision for the exposure of the nerve, 
the anesthetic solution is injected first intra dermally, to deaden the site super- 
ficiallv, and then into the tissues immediately in the neighborhood of the 
nerve', and as near to the nerve as possible. This infiltration of the tissues 
alongside of the nerve is done upon a knowledge of the anatomy of the nerve 
and its relation — and is meant to "envelop the nerve in an anesthetic atmos- 
phere." In the case of dealing with an extremity, a few minutes after the 
infiltration the part is elevated, exsanguinated by gravity, and a circular con- 
strictor applied above the region of infiltration — subsequently to which the 
parts below the infiltration will be anesthetized by the diffusion of the anesthetic 
solution (Fig. 158). In other localities no attempt to control the circulation 
is made. The anesthetic solutions and the special syringe for injection are 
mentioned under Intraneural Infiltration. Matas uses the Schleich's solution 
No. 1, calculating in this, as in other forms of regional anesthesia, not to 
leave more than 1 gr. of cocain in the tissues. To illustrate the paraneural 
method (copying from Matas' writing upon the subject) let the anesthetization 
of the finger, for the removal of a nail or the opening of a felon, be taken. 
"The skin at the root of the finger, on its dorsal aspect, is infiltrated over 
two spots on each side of the phalanx nearest the carpometacarpal joint, 
and on a level with the web of the hand. The needle is then thrust into each 
spot and directed toward the known situation of the digital nerves, which are 
deeply situated in the lateral aspect of the digits. From 10 to 15 minims of 
the anesthetizing solution are diffused in the region of each nerve, with the view 
of creating a cocain atmosphere around it. After a few minutes' delay to allow 
the capillary circulation to diffuse the fluid, the hand is exsanguinated by 
elevation, and an elastic constrictor is carried around the root of the finger 
below the seat of the infiltration. The finger will then become numb and 
dead to all painful impressions, and it will be possible to perform any operation 
upon the digit, at any point beyond the line of constriction." 

Comment. — This method is more applicable to smaller extremities and 
parts — while the intraneural method to the larger. The paraneural infiltration 
for regional anesthesia differs from local infiltration for regional anesthesia 
(which may be represented by the common use of cocain hypodermatically) 
in that in the latter no attempt is made to infiltrate along the anatomical 
course of the nerves, but the injection is made almost at random into the 
cutaneous and subcutaneous tissue. 



172 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

MASSIVE INFILTRATION ANESTHESIA WITH WEAK ANALGESIC 

SOLUTIONS. 

MATAS' MODIFICATION" OF SCHLEICH'S METHOD. 

Description. — By infiltration anesthesia is meant ihe production of 
diminished or suppressed sensibility of a part by means of edematization of 
the tissues through the injection of weak analgesic solutions. The fluid 
(from one to thirty ounces) is thrown into the tissues without reference to the 
nerves of the part — the needle avoiding important structures. (The author, 
however, has seen a quantity of the solution thrown into the internal jugular 
vein, toward the heart, in operating upon the neck, without appreciable 
result.) The analgesia thus produced is accomplished partly, and chiefly, 
by the physical effect of the pressure exercised upon the conductivity of the 
sensory nerves by the infiltrated fluid, and partly by the paralyzation of the 
sensitive structures by the chemical action of the agents used. Several 
analgesic solutions are in use, and almost any syringe may be employed for 
their introduction. Matas, whose writings on this subject have been largely 
followed, uses a special form of instrument and a special solution. 




Fig. 156. — The Latest Model of Matas' Infiltrator :- 

thesia. 



-Used In massive infiltration anes- 



Apparatus. — The infiltrator devised by Matas (Fig. 156) ''consists of 
a glass receptacle with space for 7 oz. of fluid and 2 oz. of air. The fluid is 
introduced through the bottom (or the part which becomes the bottom when 
the apparatus is inverted and ready for use) which is closed by screw-cap 
over a rubber washer which makes an air-tight joint. The bottle is graduated, 
which enables the operator to see the amount of fluid that is being used during 
an operation. The top is provided with a T-tube, with two stop-cocks, one 
for the introduction of air, and the other for the egress of the fluid. A rubber 
bulb for compressing the air is attached to the bottle by means of rubber 
tubing and suitable connections (Fig. 156). Eight needles, straight and 



MASSIVE INFILTRATION ANESTHESIA. 



173 



curved, are provided with the outfit, varying in size from a fine hypodermic 
needle to a large aspirating needle. The needles are connected to reservoir 
by rubber tubing of sufficient length to give the operator freedom of movement 
iii handling the needle. After the sterilized solution has been placed in the 
receptacle this is charged with air until marked resistance is felt in compressing 
the bulb, when the bulb and its tubing are detached from their special stop-cock. 
The apparatus is now ready for infiltration. The chief advantages of this 
apparatus over the ordinary syringes used for infiltration anesthesia are: — 
(a ) That it allows the operator to infiltrate and edematize large areas rapidly, 
continuously, or interruptedly without the delay caused by recharging or 
exchanging svringes; — (b) That by the use of long needles it tends to diminish 
the traumatism caused by frequent punctures made necessary by shorter 
needles used with the ordinary quickly exhausted syringes." 

Solutions. — The solution used by Matas for routine work is a sterilized 
j^j- of 1 per cent, eucain B solution in normal salt solution ( T 8 o- of 1 per 
cent.) — with 10 to 15 minims of 1 : 1000 adrenalin chlorid solution added 
to the total amount injected. This solution is used in bulk, up to 5 or 6 
ounces for injection into the tissues where the bulk of it will flow out — and 




Fig. 157. — The Original Type of Matas' Infiltrator: — Shown here to illustrate the 
manner of charging the receptacle with compressed air, which is done on the same general 
principle in the latest instrument. 



up to 2 ounces where this amount will be retained. The adrenalin is added 
for the purpose of producing ischaemia of the parts, especially where no form 
of constrictor can be used, and may be of benefit additionally because of its 
action upon the circulation. For preliminary intradermal injection i of 1 per 
cent, eucain B solution is used. 

Indications. — "In a general way, this method of infiltration is indicated 
in all operations in which the circulation cannot be controlled, and in which 
the major part of the infiltrating solution must remain in the tissues. By this 
method extensive extirpation of tumors, excision of malignant growths, ligation 
of all the important vessels of the neck and extremities, resection of nerves 
for neuralgia, excision of tongue, extirpation of thyroid gland, amputations, 
operations for hernia and other abdominal operations on debilitated patients, 
thoracotomy with resection of ribs, and other operations have been successfully 
performed in the clinics of the author of this method by combining the intra- 
neural method with local infiltration." 

Preparation; — Position; — Landmarks. — Dependent upon the special 
operation. 

Operation. — "In this, as in all other methods of local anesthesia, it is 



174 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

most important to remember that the derm proper, and especially its papillary 
layer, must be first edematized by intraarticular infiltration before beginning 
the infiltration of the deeper planes; the same rule applies to mucous surfaces." 
For this purpose the weaker solution above mentioned is used, carried through 
a fine needle. "The field of the operation can then be edematized, (I) in toto; 
i. e., by infiltration en bloc without reference to nerves or other anatomical 
elements (as in the extirpation of a benign tumor of the breast); or (2) by 
circumferential infiltration; i. e., by enclosing the field of operation within a 
wall of anesthetizing edema, thus cutting off the enclosed space from all nerve 
communication with the surrounding parts (e. g., the extirpation of a pedicu- 




Fig. 158. — Matas' Older Form of Infiltrator: — Shown here to illustrate the manner 
of accomplishing massive infiltration, after filling the space in the bottle with compressed air — 
the same general technic being used with the latest instrument. 

lated tumor, or sebaceous cyst)," or the amputation of a limb. Where it is 
possible to control the circulation by a constrictor, and where exsanguination 
can be practised, these should be done. "The solutions are injected tepid 
or cold into the tissues; after the infiltration is completed the entire field is 
covered with a sterilized ice-bag for three to five minutes, which by refrigera- 
ting the solution, greatly intensifies the anesthetic action." Having obtained 
loss of sensation, the operation is proceeded with as indicated in the special 
instance. During the course of an operation begun by infiltration, individual 
nerves may be taken up and injected intraneurally — or the infiltrating solu- 
tion may be deposited among the deeper tissues (Fig. 158). 



EXPOSURE OF GASSERIAN GANGLION. 1 75 



SURGICAL ANATOMY OF GASSERIAN GANGLION OF TRIFACIAL 

NERVE. 

Description and Relations. — (a) Both sensory and motor root of the 
trifacial pass downward and forward through an aperture in dura mater, 
which lies under cover of tentorium cerebelli and a little to outer side of apex 
of petrous portion of temporal bone, to enter Meckel's space, between the 
supporting and periosteal layers of dura mater, in which space the sensory 
portion enlarges into the gasserian ganglion, (b) The gasserian ganglion, of 
somewhat semilunar form, with convexity forward, rests in depression upon 
upper surface of petrous portion of temporal bone, near its apex — and also to a 
slight extent upon cartilage which occupies foramen lacerum medium. Its 
upper surface is firmly attached to dura mater (roof of Meckel's space) — its 
lower surface, less firmly (to floor of Meckel's space). Its inner part lies 
near posterior extremity of cavernous sinus and internal carotid artery. 
The motor root and the large superficial petrosal nerve lie beneath the ganglion. 
From its convex antero-external border are given off the following main 
divisions; — Ophthalmic, passing out through sphenoidal fissure; Superior 
Maxillary, passing through foramen rotundum; Inferior Maxillary, passing 
through foramen ovale and being joined immediately after its exit by the 
motor root, which also passes through foramen ovale separately. 



EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF 
FIFTH NERVE BY THE DIRECT INFRA- ARTERIAL ROUTE. 

cushing's method. 

Description. — A flap of soft parts, including the temporarily resected 
zygoma, is turned down, thus exposing the zygomatic and pterygomaxillary 
fossae. An opening is then made, with trephine or special instrument, through 
the most prominent portion of the great wing of the sphenoid, near, or including, 
the zygomatic ridge (infratemporal crest). The dura is thus reached below 
the middle meningeal artery and the ganglion exposed extra-durallv, in 
Meckel's space. The route of approach is more direct, the hemorrhage less, 
and the amount of handling of the brain less than in most of the methods of 
reaching the ganglion. 

Preparation. — Head shaved. 

Position. — Patient on back, head on one side and supported by firm 
pillow. Surgeon at side of head, either in front of or behind patient. Assis- 
tant opposite. 

Landmarks. — Outline of zygomatic arch. 

Incision. — Horse-shoe in shape, the ends of the two limbs being upon 
the outer and inner ends of the zygomatic arch, about 4 cm. (ij inches) apart, 
and the upper part of the convexity extending about 5 cm. (4 inches) above 
the zygoma. 

Operation. — (1) A skin-flap of the parts overlying the temporal fascia 
is turned down to a level just below the zygoma. The temporal vessels are 
secured. (2) A second horse-shoe incision, like the first but slightly smaller, 
is made through the temporal fascia, the base of the incision passing through 
the periosteum along the middle of the outer aspect of the zygoma. Through 
this periosteal incision free the zygoma of its periosteum except along the 
attachment of the masseter muscle. Divide the zygomatic arch at its inner 



176 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

and outer ends with a Gigli saw conducted beneath it — having first drilled on 
each side of each saw-cut, for future ligaturing. (3) Along the line of the 
limbs and convexity of the preceding horse-shoe incision divide the temporal 
muscle down to the bone. Turn the flap of soft parts, with zygoma adherent, 
downward, firmly retracting it — so as to expose the zygomatic crest (infra- 
temporal ridge), the lower part of the temporal fossa and the beginning of the 
pterygomaxillary fossa. (4) An opening is now made through the prominent 
part of the wing of the sphenoid, either by a trephine of about 3 cm. (i\ inches), 
or by means of some special instrument, with or without previous burr-openings. 
The dura in the middle fossa of the base of the skull is thus exposed at a point 
to the outer side of and about midway between the foramina ovale and rotun- 
dum — very near the foramina and below and to the outer side of the middle 
meningeal artery emerging from the foramen spinosum. (5) The Gasserian 
ganglion and its three branches are thus exposed, after gently separating the 
dura from the bony wall of the middle fossa — these structures being still 
covered by their special investment of the dura, constituting Meckel's cavity 
or space (Fig. 159). This cavity of Meckel, which it is very important to 




S BC D 



Fir. 159. — Cushing's Operation for Exposure of Gasserian Ganglion and Three 
Branches of Trifacial Nerve: — A, Gasserian ganglion; B, Ophthalmic division of fifth nerve; 
C, Superior maxillary division; D, Inferior maxillary division; E, Floor of Meckel's space; F, 
Dural arch and roof of Meckel's space; G, Middle meningeal artery. (Modified from Cushing.) 

recognize, and which it is necessary to open before coming into direct contact 
with the structures sought, is incised along its outer aspect, between the second 
and third nerves, at their entrance into their foramina. By careful blunt 
dissection the superior portion of the roof of Meckel',s space is further opened 
up, leaving the ganglion and the second and third branches exposed upon the 
floor, or lower aspect, of Meckel's space. The floor of Meckel's space is now 
separated from these structures by blunt dissection, until the ganglion is 



EXPOSURE OF GASSERIAX GAXGLIOX. 177 

raised from it. The dura is then separated on the inner side, where it lies 
in contact with the sixth nerve and cavernous sinus, the separation being 
accomplished toward the first division. The second and third divisions 
are put on the stretch gently by means of blunt hooks and divided close to their 
foramina. The body of the ganglion is seized with forceps and torn out, 
together with the origins of the second and third divisions and the first division. 
(6) Wounding of the middle meningeal artery is generally avoided. Hemor- 
rhage from small arteries and veins, and the cavernous sinus, if wounded, is 
controlled by packing temporarily. Where continuous packing is not neces- 
sitated, the wound is closed throughout, without drainage — suturing back 
the structures, including the zygoma, into normal position. The eye is covered 
with rubber protective — avoiding all pressure. 

Comment. — (1) Hemorrhage from the middle meningeal artery, the 
chief source of serious hemorrhage, is avoided by approaching the ganglion 
from below the artery. (2) The small size and protected locality of the 
opening through the skull makes the necessity of a bone-covering less than 
in the operations which reach the ganglion through the temporal fossa. (3) 
No attempt should be made to remove the ganglion until it has been freed 
from its special envelope of reflected dura — which should be accomplished 
from above first, thus lessening the hemorrhage which often accompanies the 
freeing of the ganglion from its bed. (4) The sixth nerve is often injured 
in freeing the ophthalmic division of the nerve — and the sympathetic always 
is, because of its intimate relation — but these occurrences are generallv not 
permanently serious. (5) The zygoma is sometimes not sutured back into 
position — but is allowed to sink into a less prominent position as the muscles 
of mastication atrophy. (6) It may be necessary to ligate the middle menin- 
geal artery. 



EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF 
FIFTH NERVE THROUGH TEMPORAL FOSSA BY OSTEOPLASTIC 
FLAP. 

HARTLEY-KRAUSE OPERATION. 

Description. — Osteoplastic resection of temporal region with temporary 
turning down of flap of bone and soft parts and separation of dura mater 
from middle fossa of skull — the three divisions of the fifth nerve being exposed 
and traced to the Gasserian ganglion, in Meckel's space, outside of the dura 
proper. 

Preparation. — Head shaved. 

Position. — Patient on back; head to one side and supported by firm 
pillow. Surgeon at side of head, either in front of or behind patient. Assist- 
ant opposite. 

Landmarks. — External angular process of frontal; tragus of ear; supra- 
temporal ridge. 

Incision. — A horseshoe-shaped incision is made over the temporal 
region, its anterior extremity being near the external angular process of the 
frontal bone, its posterior extremity near the tragus of the ear, and the highest 
part of the curve reaching the supratemporal ridge (Fig. 160). 

Operation. — (1) The above incision passes through all the soft tissues 
and periosteum directly to the bone, along the entire line. (2) With periosteal 
elevator, the soft parts of *' flap are freed from the bone to a slight extent 
only, around the entire i . n line — the freeing at the two ends of the base- 



178 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

line being a little more extensive. Throughout the rest of its extent, the 
flap remains adherent to the underlying bone. (3) With a trephine of about 
1.3 cm. (J inch) diameter, two discs of bone are removed, the anterior with 
its center over the tip of the sphenoid wing, the posterior having its center 
over a point 2.5 cm. (1 inch) vertically above the external auditory meatus. 
From these trephine openings the dura is separated as far as possible, both 




Fig. 160.— Exposure of Gasserian Ganglion by Osteoplastic Flai — Preparatory to the 
Hartley-Krause Operation: — I. — A, Periosteum; B, Horseshoe flap broken back and turned 
down ; C, Dura mater, with anterior and posterior branches of middle meningeal artery. 

along the straight basal line connecting the two openings, and in the direction 
in which the convex bone-section is to be made. (4) A section of bone similar 
in shape to the skin incision, but smaller in size, is now made. This section 
is made from the squamous portion of the temporal and greater wing of the 
sphenoid — the basal attachment being somewhat narrower than the greatest 



EXPOSURE OF GASSERIAN GANGLION. 



179 



transverse measurement of the convex portion. This bone-section was 
formerly made by a special chisel cutting a triangular groove- — but is now 
made by a motor or other saw — the section beginning at one trephine-opening 
and ending at the other, care being taken to do no damage to the dura. (5) 
The bone being thus cut through everywhere except across its basal line, 
some stout instrument (such as an osteotome or elevator) is inserted into the 
groove at its greatest convexity, resting against the parietal bone as a fulcrum 
— then, with a sharp, sudden movement, this flap of skin, muscle, periosteum, 




Fig. 161. — Exposure of Gasserian Ganglion" and Roots of Trifacial Nerve by 
Osteoplastic Flap, by the Hartley-Krause Method: — II. — A, Retractor elevating brain 
and exposing middle fossa of skull; B, Gasserian ganglion, with first division of trifacial nerve 
passing through sphenoidal fissure, second division through foramen rotundum, and third 
division through foramen ovale; C, Middle meningeal artery entering through foramen spinosum; 
D, Position of cavernous sinus and internal carotid artery; the third, fourth, and sixth nerves 
are seen between the cavernous sinus and the first division of the fifth nerve. The lamina of 
dura forming Meckel's space has been incised over the ganglion and the third division, but is 
not accurately shown in its reflection forming the roof of Meckel's cavity. Note: — the ganglion 
and branches are represented somewhat disproportionately large and prominent, as well as 
upon too high a plane. 

and bone is prized outward and downward, generally snapping directlv and 
evenly across the basal line just above the zygomatic arch, and remaining 
hinged by the soft parts — and exposing an area of brain (covered by dura 
mater) of about 5 to 7.5 cm. (2 to 3 inches) in diameter (Fig. 161). (6) If 



180 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

the middle meningeal artery is found injured, it is tied as near the foramen 
spinosum as possible. (7) The dura mater and temporosphenoidal lobe of 
the brain are now separated from the middle fossa of the skull. This is done 
in the direction toward the apex of the petrous portion of the temporal bone, 
and is accomplished by the fingers or a piece of gauze, or by a curved, blunt 
elevator. Sometimes the dura is considerably torn, and sometimes the 
artery is torn whether the dura is or not, requiring temporary packing of 
the bony groove to control the hemorrhage, where ligature is impossible. 
Injured dura should be sutured wherever possible. (8) The three divisions 
of the nerve are now seen and are traced back from their foramina. The 
positions of the carotid artery and cavernous sinus are located as nearly as 
possible, for the purpose of guarding them. (9) Isolate and cut the first, 
second, and third divisions close to the sphenoidal fissure, foramen rotundum, 
and foramen ovale, respectively. Secure the proximal ends of the severed 
nerves with forceps or silk, and, practising traction upon them, trace them 
back to the gasserian ganglion — after incising the dura mater over them. 
Then, raising the ganglion from its bed, sever its connections with the brain 
close to the dura mater, and, if possible, without including or injuring the 
motor root. (10) At the end of the operation the dura and unexposed cerebral 
convolutions are allowed to fall into place — the flap of bone and soft parts is 
turned up — and sutures applied to skin and muscles. 

Comment. — (1) The width of the basal line of bone may be decreased 
by rongeur forceps, thus increasing the likelihood of a clean, transverse 
breakage — or a Gigli saw may be conducted under the bone at its base and 
made partly to divide it. (2) In the use of either chisel or saw, the inner 
tablet of the skull may be left uncut in two or three places, over a limited 
extent, so that when the flap is broken back, these parts of the vitreous are 
left as shelves for the flap to rest upon when turned back into place. (3) 
Bleeding may be so great as compel one to pack and finish the operation in 
two stages. (4) The advisability of removing the first division is doubtful, 
because of the trophic changes which follow in the eye. The first division 
is never involved alone. (5) The motor root should always be left undisturbed, 
if possible — to avoid paralysis of the muscles of mastication. It is more apt to 
be injured if the dura of Meckel's space be opened over the ganglion and the 
sensory root be cut between the ganglion and the pons. When possible it is 
best to cut the second and third divisions close to the foramen rotundum and 
foramen ovale respectively — dissect them back to the ganglion, and remove the 
parts of the ganglion corresponding to these divisions, leaving untouched the 
first division, with its corresponding ganglion and the motor root. (6) If the 
first division be removed, with the corresponding part of the ganglion, especial 
care is needed not to harm the cavernous sinus and the nerves to the eye — 
to aid in avoiding which, the second and third divisions should be removed 
first to give more room. If the first division be accidentally severed, leave 
the lacerated end as near the remains of the ganglion as possible. (7) If 
much oozing follows packing, wick or gauze drainage is indicated for twenty- 
four or forty-eight hours. (8) The chief dangers of the operations are — ■ 
injury to internal carotid and cavernous sinus; laceration of brain; injury 
to nerves of eye (third, fourth, and ophthalmic division) ; hemorrhage from 
middle meningeal artery. (9) In Horsley's method of intracranial exposure 
of the gasserian ganglion a large soft flap is turned down from the temporal 
region, the underlying bone is removed by trephine and bone forceps (not 
to be returned), the temporosphenoidal lobe exposed, the dura incised, the 
ganglion exposed, and the root cut on the proximal side of the ganglion. 



EXPOSURE OF GASSERIAN GANGLION. 181 

EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF 
FIFTH NERVE BY TREPHINING THROUGH PTERYGOMAXILLARY 
FOSSA. 

rose's method. 

Description. — The ganglion is approached through the pterygomaxillary 
fossa, the zygoma being temporarily and the coronoid process of the inferior 
maxilla permanently resected, and the trephine applied to include the anterior 
and outer portion of the foramen ovale. The dura proper is not opened. 

Preparation. — Head shaved; eyelids stitched together with temporary 
sutures. 

Position. — As in preceding operation. 

Landmarks. — ( >uter canthus of eye; zygomatic arch; meatus auditorius 
externus; angle and horizontal ramus of lower jaw. 

Incision. — Begins near outer canthus of eye, about 1.3 cm. (h inch) 
below the external angular process of the frontal — passes backward along 
the upper border of the zygoma to its posterior extremity — thence downward 
just in front of ear to the angle of the jaw — thence forward along the horizontal 
ramus of the jaw to the facial vessels. 

Operation. — (1) Reflection of the Skin Flap; — Incise through skin and 
fascia only, along the above line. Raise this semicircular skin flap without 
harming the facial nerve or Stenson's duct. (2) Exposure of the Pterygoid 
Space; — Incise down through the periosteum for the entire length of the 
zygoma, and detach the periosteum. Drill (for later wiring of the bones) 
two holes through the zygomatic process of the malar, and two through the 
root of the zygoma. Divide the bone (downward and forward) between the 
two anterior holes — and also between the two posterior holes. Displace the 
zygoma downward and backward, bringing the masseter with it (dividing 
the necessary muscle-fibers). The coronoid process is exposed and cut 
obliquely downward and forward, as low as possible, then turned upward, 
and, together with tendon, cut away (there being no object in retaining it, 
as it would waste with the other muscles of mastication supplied by the 
motor fibers of the third division). (3) Exposure of the Foramen Ovale; — 
Expose the internal pterygoid by removing the overlying fat and connective 
tissue. The internal maxillary artery, which is generally found upon the 
muscle, is divided between two ligatures. The inferior dental and lingual 
gustatory nerves are sought at the lower border of the external pterygoid, 
cut, and their proximal ends tied with silk, to serve as guides. Expose the 
foramen ovale on the under surface of the great wing of the sphenoid, by 
partly cutting away and partly retracting away (by scraping) the external 
pterygoid — thus exposing both the great wing of the sphenoid and the external 
pterygoid plate. The foramen ovale is sought by following up the silk liga- 
ture, drawing the nerves of the third division taut, and also by the finger 
feeling in its known position, a little behind and external to the external 
pterygoid plate, remembering that just to the inner side and behind the 
foramen ovale lie the eustachian tube and the middle meningeal artery about 
to enter the foramen ovale. Bleeding is apt to be considerable here, espe- 
cially from the veins of the pterygoid plexus and from veins passing through 
the foramen ovale between the pterygoid plexus and the cavernous sinus. 
This hemorrhage is controlled by gauze packing. (4) Opening the Base 
of the Skull; — A small, long-handled trephine is placed just in front and 
to the outer side of the foramen ovale, so that the margin of the foramen is 
included in the disc of the bone to be removed. (5) Division of Nerve- 
trunks and Partial Removal of the Ganglion; — The trephine-opening having 



182 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

been cleared and sufficiently enlarged by chisel or forceps, the surgeon follows, 
by means of the silk ligature, the third division up to the ganglion, which is 
Loosened from its bed and its second and third divisions freely resected — 
the first being left undisturbed. (6) Closure of the Wound;— The wound 
having been irrigated with i : 4000 bichlorid, dried and dusted with iodoform, 
the previously drilled zygoma is wired, the temporal fascia sutured to the cut 
margin of the fascia over the zygoma, and the wound closed without drainage. 
The eyelid stitches are removed in three or four days. 

Comment. — (1) The operation may be performed in two stages. (2) 
The coronoid process may be drilled (for wiring) before cutting. 



SURGICAL ANATOMY OF SUPRAORBITAL BRANCH OF FRONTAL 

NERVE. 

Description. — Passes forward from bifurcation of frontal nerve and 
leaves orbit through supraorbital notch (or foramen) — and, giving off palpebral 
branches, ascends vertically upward close to bone, beneath orbicularis pal- 
pebrarum and occipitofrontalis to forehead, where it divides into cutaneous 
and pericranial branches. The supraorbital vessels lie on its outer side. 



EXPOSURE OF SUPRAORBITAL BRANCH OF FRONTAL AT 
SUPRAORBITAL FORAMEN. 

Position. — Patient supine; head slightly elevated. Surgeon on side of 
operation, or above head. 

Landmarks. — Supraorbital notch (or foramen) — which, if not easily 
felt, lies at junction of inner and middle thirds of supraorbital margin. 

Incision. — Transverse, about 2.5 cm. (1 inch) in length, along supra- 
orbital margin, with center over position of supraorbital notch (or foramen) 
— the evebrow having been previously shaved. 

Operation. — Having steadied the brow by the first finger of left hand 
(which also draws up the soft parts so as to hide subsequent scar) and de- 
pressed lid with left thumb, carry the above incision through skin, fascia, 
and orbicularis palpebrarum — when the nerve will be found upon the peri- 
osteum, accompanied by its vessels. (Fig. 104). 



SURGICAL ANATOMY OF SUPERIOR MAXILLARY BRANCH OF TRI- 
FACIAL AND MECKEL'S GANGLION. 

Description. — Arises from center of gasserian ganglion — runs forward 
through foramen rotund urn — traverses upper part of sphenomaxillary fossa 
— enters orbit through sphenomaxillary fissure — thence courses forward along 
infraorbital groove, accompanied by infraorbital artery, to infraorbital canal 
— along which it passes to emerge upon face through infraorbital foramen, 
as the infraorbital nerve, terminating beneath levator labii superioris muscle 
in a leash of branches. The distance of infraorbital foramen from foramen 
rotundum is about 5 cm. (2 inches). 

Sphenopalatine or Meckel's Ganglion. — Placed deeply in spheno- 
maxillary fossa, beneath superior maxillary nerve, near sphenopalatine 
foramen. Its relations are: — Superiorly, superior maxillary nerve; Poste- 



EXPOSURE OF SURERIOR MAXILLARY XERVE. 



I8 3 



riorly, sphenoid bone and Vidian canal; Externally, internal maxillary artery 
and external pterygoid muscle; Internally, vertical plate of palate and spheno- 
palatine foramen. 

Comment. — The posterior superior dental is given off from the superior 
maxillary just before the nerve enters the infraorbital canal — the middle 
superior dental, at the back part of the canal — and the anterior superior 
dental just before its exit upon the face. To insure, therefore, the removal 
of the origin of the posterior superior dental nerve, the trunk has to be 
removed as far back as Meckel's ganglion. . 



EXPOSURE OF SUPERIOR MAXILLARY NERVE AT FORAMEN RO- 
TUNDUM BY OSTEOPLASTIC RESECTION OF MALAR AND ADJA- 
CENT BONES. 

kocher's operation. 

Description. — Having temporarily raised a bony flap (composed of the 
parts mentioned below), the infraorbital nerve is liberated and traced back to 
the superior maxillary nerve and Meckel's ganglion, at the foramen rotundum 
in the sphenomaxillary fossa. 




Fig. 162. — Skin* Incisions for Exposure of Superior and Inferior M\xillary 
Nerves: — A, Kocher's incision for osteoplastic exposure of superior maxillary nerve at foramen 
rotundum; B, Kocher's incision for osteoplastic exposure of inferior nerve at foramen ovale. 



Position. — Patient supine; head elevated and turned to opposite side. 
Surgeon on side of operation. 

Landmarks. — Infraorbital foramen; infraorbital margin of orbit; malar 
bone. 

Incision. — Begins 1 cm. (nearly h inch) internal to the infraorbital 
foramen, and \ cm. (about \ inch) below the inner end of the infraorbital 
margin — -and runs almost horizontally outward, with slight downward inclina- 
tion, over the inferior aspect of the malar, to end over the zygoma (Fig. 162, A). 

Operation. — This incision exposes the angular artery at it- inner end, 
enabling the vessel to be displaced further inward or ligated. Steno's duct 
lies below the incision. The inner end of the incision passes down to the bone 



184 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

between the fibers of the orbicularis palpebrarum and the levator labii 
superioris. The orbicularis, together with the periosteum, is raised from the 
bone as far upward as the orbit. The levator labii superioris is dissected 
subperiosteal! v down to the infraorbital foramen, where the infraorbital 
nerve is secured with a tenaculum or ligature. The outer portion of the 
incision runs above the origins of the zygomatici — these are detached down- 
ward — and the anterior fibers of the masseter are separated from the inferior 
and internal aspects of the malar. The external and internal surfaces of the 
malar are thus bared. The malar process of the superior maxilla is bared, 
upon its anterior surface, up to the infraorbital foramen — and, upon its 
superior surface, as far posteriorly as the sphenomaxillary fissure. Retract 
the upper edge of the wound upward sufficiently to expose the frontomalar 
suture, which is so chiseled through toward the posterior part of the spheno- 
maxillary fissure that its superior border, the orbital process of the malar, 
part of the orbital plate of the sphenoid, and part of the zygomatic process 
can be raised (Fig. 163). Anteriorly, the bone is chiseled through from 




Fig. 163. 



-Bone Sections in Kocher's Osteoplastic Exposure of Superior Maxillary 
Nerve at Foramen Rotundum. 



above the infraorbital nerve (in such a manner that the roof of the infraorbital 
canal is carried away) downward and outward, to below the anterior border 
of the origin of the masseter — and then upw 7 ard through the external wall of 
the antrum until it meets, posteriorly, the section through the orbital structures. 
Thus the external part of the orbital plate and the supero-external wall of the 
antrum, along with its posterior angle, remain connected with the malar bone, 
when the latter is levered out. Having raised the orbital fat with a special 
elevator and protected the globe of the eye, the mass of bone is dislodged 
upward and outward from the wound by means of a stout hook or periosteal 



EXPOSURE OF SUPERIOR MAXILLARY NERVE. 185 

elevator. The infraorbital nerve, which is kept taut by the ligature attached 
to it, is now traced through the upper part of the opened antrum to the foramen 
rotundum. A small, blunt hook is carried behind the descending spheno- 
palatine nerves and made to grasp the main trunk, which is then divided or 
wrenched out. The accompanying infraorbital artery is either retracted or 
ligated. The malar bone, with its attached bony fragments, is now put back 
into its normal position — where it will generally remain without sutures, 
although fixation sutures may be used if desired. The soft parts are closed 
without drainage. No harm is ordinarily done by opening the antrum — 
and verv little disfigurement results. 



EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
GANGLION BY THE ANTRAL ROUTE. 

CARXOCHAN'S OPERATION. 

Description. — The superior maxillary nerve is removed from the infra- 
orbital foramen to the foramen rotundum, together with Meckel's ganglion— 
by following the course of the infraorbital canal, and removing parts of the 
anterior wall, roof, and posterior wall of the antrum of Highmore. 

Position. — Patient supine; head elevated and turned slightly to one side. 
Surgeon on side of operation. 

Landmarks. — Infraorbital foramen (which is about S mm. — J inch — 
below the infraorbital margin, and on a line drawn from the supraorbital 
foramen to a point between the two bicuspids of both jaws). 

Incision. — -V-shaped (two sides of an equilateral triangle, each side 
being about 2.5 cm. — 1 inch — long), placed with its center over the infraorbital 
foramen and its two limbs upward. 

Operation. — (1) This incision is carried to the bone. The flap is then 
turned up over the closed eye and its apex stitched to the forehead. (2) 
The infraorbital nerve is isolated at the foramen, cut as long as possible, 
and tied with silk — to serve as a guide and means of traction. (3) A trephine 
of about 1.3 to 2 cm. (§ to f inch) in diameter, or a chisel, is now applied to 
the cleared bone, and a portion of bone removed including the foramen in its 
upper half — and the mucous membrane of the antrum is incised. (4) The 
upper portion of the posterior wall of the antrum is similarly removed over 
an area of about 6 mm. (\ inch), either by trephine or chisel. (5) The mucous 
membrane covering the roof of the antrum is now divided in the direction 
of the infraorbital canal, followed by breaking away the bony floor of the 
canal, which may be done by chisel or stout scissors, while practising traction 
upon the nerve as a guide. (6) By this means, and by the use of long slender 
scissors and dissecting forceps, the nerve is freed back across the spheno- 
maxillary fossa to the foramen rotundum, until it hangs freely exposed. 

(7) Effort should be made to recognize Meckel's ganglion at this stage, locating 
it as definitely as possible. Considerable bleeding may be expected at this 
period of the operation — hemorrhage being controlled chiefly by pressure. 
Artificial illumination should be used. The nerve, while slight traction is 
being applied, should be divided at the foramen rotundum and from its 
sphenopalatine branches. The nerve and ganglion are then withdrawn. 

(8) The soft parts are now sutured — and, if much oozing occur, temporary 
drainage is to be provided for through the lower angle of the wound, or tem- 
porary packing may be necessary, with subsequent suturing of the lower 
part of the wound. 



186 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Comment. — (i) A T-shaped incision may be used — the horizontal 
portion being placed under the lower margin of the orbit, and the vertical 
portion running down on the cheek to near the mouth. Or a r -shaped 
incision may be used — the horizontal portion along the orbit, and the vertical 
portion in the nasolabial groove. Probably the best incision is a long trans- 
verse one below the orbital margin, with strong retraction. (2) When 
Meckel's ganglion is removed, the vidian nerve is paralyzed and therefore 
the motor branches to the palate muscles. 



EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
GANGLION BY THE ORBITAL ROUTE. 

Description. — After subperiosteally displacing the contents of the orbit 
from the infraorbital canal and removing the roof of the canal, the nerve 
is followed back to and beyond Meckel's ganglion and cut at the foramen 
rotundum. 

Position. — As in the above operation. 

Landmarks. — Infraorbital margin and infraorbital foramen. 

Incision. — Curved incision along lower margin of orbit over infraorbital 
foramen — extending from near internal angular process to external angular 
process of frontal. 

Operation. — Carry the incision to the bone throughout. Isolate the 
nerve — cut as long as possible — and attach a stout piece of silk to the proximal 
end as a guide and means of traction. The bone between the infraorbital 
foramen and infraorbital margin is removed by trephine or chisel, exposing 
the anterior portion of the infraorbital canal. The periosteum of the floor 
of the orbit is raised along the orbital margin with a periosteal elevator — 
a spatula or retractor is placed beneath this and the tissues of the orbit are 
held out of the way. The roof of the canal is next broken down with a fine 
chisel, or other instrument — bleeding being controlled by pressure— and the 
nerve lifted out of its bed by traction on the ligature — and is then traced 
back with delicate instruments to the foramen rotundum and removed, 
together with Meckel's ganglion and its terminal filaments. The orbital 
contents are then allowed to fall back into place and the skin incision sutured. 

Comment. — It is exceedingly difficult, and probably impossible, actually 
to leach the ganglion by this method, especially without wounding the eye- 
structures. It is also difficult to make the section far enough back to include 
all the dental nerves. 



EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
GANGLION BY THE PTERYGOMAXILLARY ROUTE. 

BRAUN-LOESSEN OPERATION. 

Description. — The nerve and ganglion are reached in the pterygo- 
maxillary fossa by temporarily resecting the zygoma, turning it and the 
masseter muscle downward, firmly retracting the temporal muscle backward, 
and following the posterior surface of the superior maxillary bone into the 
pterygomaxillary fossa. 

Position. — Patient supine; head on one side and elevated; surgeon to 
right for both sides. 



EXPOSURE OF SUPERIOR MAXILLARY NERVE. 187 

Landmarks. — External angular process of frontal; zygoma; posterior 
border of ascending ramus of lower jaw. 

Incision. — Begins at external angular process of frontal, passes downward 
and backward along upper border of zygoma to tragus of ear, thence down- 
ward in front of ear along posterior margin of inferior maxilla to angle of 
lower jaw. 

Operation. — (1) This incision (the region having been shaved) passes 
only through skin and superficial fascia — and the flap of integumentary 
tissues thus raised by dissection is turned forward and temporarily attached 
to the nose by suture. (2) An incision is made along the zygoma, passing 
to the bone, which is then exposed subperiosteally. Two holes are drilled 
(for wiring the bone later) through the malar bone on a line with a continua- 
tion of the upper part of its posterior border, and two through the zygoma 
near its root. The zygomatic arch is then sawed through between the two 
anterior drill-holes and between the two posterior drill-holes, directing the 
saw from without inward at the two ends (forming a beveled shelf for the 
arch to rest upon when replaced). The temporal fascia has been freed 
along its upper border in exposing the arch — and now the entire arch is 
turned down, with its attached masseter, cutting whatever fibers of that 
muscle are still holding the arch in place. (3) At this stage the mouth is 
opened with a gag and the lower jaw depressed, to carry downward and 
backward the coronoid process, with its temporal attachment — at the same 
time drawing backward with retractors the temporal muscle and tendon 
from the anterior portion of the temporal fossa. If this do not give sufficient 
exposure, the anterior part of the muscle and tendon is divided transversely. 
(4) The pterygomaxillary fissure is thereby exposed — and the internal maxil- 
lary artery and vein are seen entering and leaving the pterygomaxillary 
fossa through this fissure and are both ligated. The superior maxillary 
nerve is found leaving the foramen rotundum and is brought forward by 
means of a nerve-hook. The nerve and Meckel's ganglion can be more 
thoroughly exposed, at this stage of the operation, by chiseling away the 
spur of bone at the base of the external pterygoid plate, projecting outward 
and forward across the pterygomaxillary fissure and partially blocking the 
entrance to the pterygomaxillary fossa — and then both nerve and ganglion 
can be hooked forward. (5) In concluding the operation, the temporarily 
removed zygomatic arch is wired at both ends where previously drilled. If 
the temporal muscle have been partly severed, this is sutured. The temporal 
fascia is sutured to the cut margin of fascia over the zygoma. The skin 
incision is closed as usual. 

Comment. — (i) If the infraorbital nerve be exposed at its emergence 
upon the face from the infraorbital foramen and be severed, then by traction 
upon the nerve hooked up in the sphenomaxillary fossa the entire length 
of the infraorbital nerve may be drawn out of the canal backward and all its 
dental branches torn across in their bony canals. (2) This operation is 
similar, in principle, to Rose's method of exposing the gasserian ganglion— 
and the chief indication for its use is where it is found desirable to expose 
the inferior maxillary at the foramen ovale, as well as the superior maxillary, 
with Meckel's ganglion, at the foramen rotundum. To expose the superior 
maxillary and Meckel's ganglion alone, the antral or the orbital route would 
be preferable; — and to expose all three roots, or the second and third, the 
Hartley-Krause or the Rose operation, especially the former, would be better. 



1 88 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

EXPOSURE OF INFRAORBITAL NERVE AT INFRAORBITAL 

FORAMEN. 

Position. — Patient's head slightly elevated. Surgeon to side of operation. 

Landmarks. —Infraorbital foramen — which, if not palpable, lies about 8 
mm. (J inch) below infraorbital margin, and on line from supraorbital foramen 
to a point between the two bicuspids in both jaws. 

Incision. — About 2 cm. (f inch) in length, over the infraorbital foramen, 
parallel with the margin of the orbit. 

Operation. — Skin, fat, and orbicularis palpebrarum are incised. The 
levator labii superioris is exposed and also incised. The nerve is found at 
its emergence from the foramen. (Fig. 106). 

Comment. — The infraorbital nerve may be exposed through the mouth, 
without scarring. Having made the gingivolabial fold tense, an incision is 
made through the mucous membrane and periosteum along the line of reflec- 
tion from the upper lip to the superior maxilla. The soft parts are then 
dissected away from the bone along the canine fossa, subperiosteally, and 
firmly retracted upward — until the infraorbital foramen is reached. 

Note. — For the Anatomy of the Infraorbital, see the Superior Maxillary 
nerve. 

SURGICAL ANATOMY OF INFERIOR MAXILLARY BRANCH OF TRI- 
FACIAL AND THE OTIC AND SUBMAXILLARY GANGLIA. 

Description of Inferior Maxillary. — Formed of two roots — a large 
sensory root from the inferior angle of gasserian ganglion — and a small 
motor root which passes under the ganglion and unites with the sensory root 
just after it has passed through the foramen ovale — both roots passing through 
the foramen separately. The nerve divides into anterior and posterior divi- 
sions 3 to 4 mm. Q inch, about) beneath the base of skull and under cover 
of the external pterygoid — the former receiving the greater part of the motor 
root and the latter the greater part of the sensory root. 

Ganglia. — (1) Otic (Arnold's) Ganglion; — situated immediately beneath 
foramen ovale, having inferior maxillary nerve on its outer side, the eustachian 
tube on its inner side, and the middle meningeal artery on its posterior side. 
(2) Submaxillary Ganglion; — placed between mylohyoid and hyoglossus 
muscles, above deep portion of submaxillary gland, and at outer side of 
Wharton's duct. 

Note. — Foramen ovale lies on a line connecting the eminentia articularis, 
at root of zygoma, of one side, with that of the other, and about 3 cm. (if 
inches) from the eminentia — and is directly posterior and a little external 
to the external pterygoid plate. The middle meningeal artery enters the 
foramen spinosum just behind the foramen ovale. (3) The internal maxillary 
artery, in its second part, runs forward and upward on outer surface of external 
pterygoid muscle. (4) The pterygoid plexus of veins lies on the external 
pterygoid muscle. 

EXPOSURE OF INFERIOR MAXILLARY NERVE AT FORAMEN OVALE 
BY OSTEOPLASTIC RESECTION OF MALOZYGOMATIC ARCH. 

kocher's operation. 

Description.— Having temporarily resected the malozygomatic arch, 
the pterygomaxillary fossa is exposed, and the third division of the fifth nerve 
traced to its exit from the foramen ovale. 



EXPOSURE OF INFERIOR MAXILLARY NERVE. 



189 



Position. — Patient supine; head elevated and turned to opposite side. 
Surgeon on side of operation. 

Landmarks. — Frontal process of malar; posterior extremity of zygoma; 
pinna of ear. 

Incision. — Begins just posterior to the frontal process of the malar — 
passes thence obliquely downward and backward to the posterior end of the 
zygoma — and is carried thence upward and backward, in front of the ear, 
at right angles to the first portion of the incision (Fig. 162, B). 

Operation. — The first part of this incision is superficial — the latter 
portion, passing upward in front of the ear, is carried down to the bone, 
and the temporal vessels ligated. More anteriorly the incision divides the 
skin, superficial fascia, dense temporal fascia, and some fibers of the orbicularis 
palpebrarum — all of which are displaced downward, together with branches 
of the facial nerve going to the orbicularis and frontal muscles. The malar 
bone is exposed just behind its frontal process and divided vertically with a 




Fig. 164. — Bone Sections for Kocher's Osteoplastic Exposure of Inferior Maxillary 
Nerve at Foramen Ovale, at Malar and Zygoma. 



saw (Fig. 164). The zygoma is similarly divided transversely near its 
posterior root. The malozygomatic arch is then displaced downward with a 
strong hook. The external aspect of the temporal muscle is thus exposed — 
and its posterior and inferior borders are separated from the skull and retracted 
firmly forward. If necessary to afford freer access — which is rarely the 
case — the temporal insertion into the coronoid may be divided, or the coronoid 
itself be removed. Forward retraction of the temporal, however, is usually 
sufficient — together with the forward displacement, by retraction, of the 
structures of the retromaxillary fossa. All the soft parts, together with the 
periosteum, are thus liberated and retracted forward and inward — thereby 
exposing the external aspect of the pterygoid process — just posterior to the 
sharp edge of which the foramen is readily palpable, lying about 3 cm. (ij 
inches) internal to the zygomatic process. The middle meningeal artery, 
entering the foramen spinosum, lies just behind. The branches of the max- 
illary lie in the parts already retracted downward. The sometimes severe 
hemorrhage can be controlled by packing temporarily. The inferior maxillary 



190 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

nerve is seized near its exit with a small, blunt hook and drawn forward — and 
is then grasped with forceps and removed entire. If the hemorrhage have 
ceased, and it is certain all the nerve has been removed, the malozygomatic 
arch is replaced and sutured into position and the wound closed throughout. 
If, on the other hand, hemorrhage persist, and there is uncertainty as to the 
nerve, the wound is packed for a time — and reopened in one or two days — 
and then secondarily sutured. The scar following the operation is not promi- 
nent. 



EXPOSURE OF INFERIOR MAXILLARY NERVE AT FORAMEN OVALE 
—OR OF SUPERIOR MAXILLARY NERVE AT FORAMEN ROTUNDUM. 

MIXTER'S OPERATION. 

Description. — Mixter's operation consists in a temporary excision and 
downward displacement of the zygomatic arch, with the attached masseter 
— followed bv a backward displacement of the temporal muscle, to reach 
the superior maxillary nerve and foramen rotundum — and a forward dis- 
placement of the muscle to reach the inferior maxillary and foramen ovale. 
The inferior maxillary nerve may be exposed at its origin by any of the opera- 
tions exposing the gasserian ganglion, either intracranially or extracranially. 

Position. — Patient on back; head elevated and turned to one side. Surgeon 
on side of operation, or to right for both operations. 

Landmarks. — Zygoma; temporal ridge. 

Incision. — Curved, with convexity upward — beginning about 1.3 cm. 
{\ inch) below malar portion of zygomatic arch and passing upward along 
posterior margin of malar bone and external angular process of frontal bone, 
to commencement of temporal ridge — thence follows lower temporal ridge 
to opposite anterior margin of ear — and then curves downward to pass in 
front of ear and ends about 1.3 cm. (J inch) below root of zygoma. 

Operation. — The above incision is made through the shaved skin and 
through the fascia — and this flap is turned downward, guarding Steno's duct. 
The temporal artery is ligated, unless it can be displaced backward. The 
zygomatic arch is exposed subperiosteal!}- and sawed through in front and 
behind, beveling from without inward — and guarding against opening the 
inferior maxillary articulation behind. The zygoma, attached masseter, and 
fatty connective tissue are now well retracted downward. The temporal 
muscle and its attachment to the coronoid process become thereby well exposed 
— and are manipulated in accordance with the structure sought: — (a) To 
Expose the Superior Maxillary Nerve and the Foramen Rotundum: — The 
temporal muscle and tendon are firmly retracted posteriorly, by a broad, 
smooth retractor, aided by an assistant's depressing the jaw — the surgeon 
being guided by the posterior wall of the superior maxillary bone and the 
spur of bone projecting forward and outward from the base of the external 
pterygoid plate. This spur is chiseled away to better expose the foramen 
rotundum, if necessary — the chiseling being done in a forward and slightly 
inward direction, to avoid going into the middle fossa of the skull. Having 
removed this spur, the superior maxillary nerve is to be found crossing the 
pterygomaxillary fossa from the foramen rotundum to the infraorbital foramen, 
with Meckel's ganglion beneath it, and near the sphenopalatine foramen, 
(b) To Expose the Inferior Maxillary Nerve and Foramen Ovale: — The 
temporal muscle and tendon are now firmly retracted forward (the jaw 
being now closed to carry the coronoid process forward) — the surgeon being 



EXPOSURE OF INFERIOR DENTAL NERVE IN MOUTH. 191 

guided to the foramen ovale by its position just posterior and external to the 
base of the external pterygoid plate, at a distance of about 3 cm. (1^ inches) 
internal to the anterior margin of the posterior attachment of the zygoma 
and slightly posterior to this line drawn directly inward. On the way inward 
the internal maxillary artery is met on the external pterygoid muscle and 
ligated. The pterygoid plexus of veins also lies upon this muscle. The 
external and internal pterygoid muscles can generally be displaced by retrac- 
tion without necessitating their incision. The foramen ovale is usually 
recognized by the tip of the finger and the nerve is exposed emerging from 
it and drawn forward by a hook. Free hemorrhage may necessitate packing 
one part of the wound while working in another. In concluding the operation 
for exposure of either structure, the zygoma is replaced and the flap turned 
back into position. 

Comment. — (I) If the zygoma be drilled anteriorly and posteriorly 
and then sawed between each pair of drill-holes, it may be subsequently 
wired. (2) If sufficient room cannot be gotten by retraction of the temporal 
muscle and tendon, it may be divided in part, transversely — the anterior 
portion being cut to reach the foramen rotundum — and the posterior portion 
in order to reach the foramen ovale. The muscle should be sutured on 
completing the operation. (3) The coronoid process could be drilled, sawed 
between the drill-holes, and the coronoid tip and temporal attachment turned 
upward — to be afterward sutured back in place. (4) As much of the pterygoid 
muscles (especially the external) may be divided, or drawn away from its 
origin at the sphenoid, as needed. But the less the detachment of the tem- 
poral and pterygoid muscles, the less the involvement of the jaw articulation 
subsequently — except that caused by paralytic atrophy if the motor part of 
the third division be cut. (5) The motor part of the inferior maxillary is 
to be avoided if possible — but is generally unavoidably included in the destruc- 
tion of the sensory portion. 

SURGICAL ANATOMY OF INFERIOR DENTAL NERVE. 

Description and Relations. — A sensory nerve — a branch of inferior 
maxillary nerve, passing down under cover of external pterygoid muscle, it 
descends to outer side of internal pterygoid, to interval between ramus of 
inferior maxilla and internal lateral ligament, to dental foramen — accom- 
panied by inferior dental artery and having lingual nerve in front and internal 
to it. The mylohyoid branch is given off just before the nerve enters the 
dental canal, and the mental branch at its exit at the mental foramen. The 
dental foramen is surrounded by the lingula of Spix, to which is attached 
the internal lateral ligament, the groove for the mylohyoid nerve being just 
behind it and the attachment of the internal pterygoid muscle reaching to 
its base. The inferior dental vessels pass along behind and outside the 
nerve. The internal maxillary artery passes safely above the dental foramen. 



EXPOSURE OF INFERIOR DENTAL NERVE IN MOUTH 

PARAVICINI'S INTRABUCCAL METHOD. 

Position. — Patient supine; head slightly raised; gag in opposite side of 
mouth; cheek of operated side held open by retractors and commissure of 
mouth drawn backward. Surgeon faces patient and stands on his right for 
both operations. A head-mirror should be used. 



192 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Landmarks. — Ascending ramus of jaw; spine of Spix; internal pterygoid 
muscle. 

Incision. — About 2.5 cm. (1 inch) in length — along anterior border of 
ascending ramus of inferior maxilla, about 7 mm. (^ inch) to inner side 
of sharp anterior border of coronoid process, and ending over the spine of 
Spix. 

Operation. — Having incised and detached the mucous membrane and 
periosteum, feel for the spine of Spix — cutting the internal lateral ligament 
with scissors if necessary in order to expose the nerve entering the foramen — 
which is then isolated and drawn forward. The inferior dental artery lies 
in close contact and should be avoided. In completing the operation, it is 
better to close the incision with sutures — though these are often omitted. 

Comment. — Expose the dental foramen that the lingual may not be 
taken for the inferior dental nerve. If possible, avoid injuring the internal 
lateral ligament, which is attached to the spine of Spix. 

EXPOSURE OF INFERIOR DENTAL THROUGH ASCENDING RAMUS 
OF INFERIOR MAXILLA. 

Description. — The outer aspect of the lower jaw is exposed and the 
nerve reached by trephining the bone. 

Position. — Patient's head turned to one side and slightly elevated. 
Surgeon on side of operation. 

Landmarks. — The four borders of the ascending ramus of the inferior 
maxilla. 

Incision. — Curved, circumscribing the angle and lower half of ascending 
ramus of lower jaw — the transverse curve being just above the lower margin 
— and the vertical limbs corresponding with the anterior and posterior borders. 
Thus Stenson's duct escapes and but few branches of the facial nerve are 
injured. 

Operation. — This incision is first carried through skin and superficial 
fascia, when whatever nerves are in line of incision are retracted (especially 
the buccal and supramaxillary) — then through masseter and periosteum to 
bone. The soft parts are now freed from bone subperiosteally and retracted 
strongly upward, gaining room by this upward retraction without harm to 
the facial nerve or Stenson's duct. A window of bone, having its center 
corresponding with this quadrilateral surface of bone, is then removed with 
the trephine or chisel (a disc about 1.3 to 2 cm. — h to f inch — in diameter), 
remembering that the lower and anterior part of the ascending ramus is 
much thicker than the upper and posterior. Approach the nerve and accom- 
panying artery with care, elevating, rather than chiseling or trephining, the 
last thickness of bone. The nerve is then isolated in its canal. 

Comment. — (1) The nerve can be reached at its entrance into the dental 
canal and traced up to the foramen ovale by an extension of this operation, 
by widening the sigmoid notch. The incision passes through skin and 
superficial fascia only — beginning at the middle of the zygoma, passing 
backward and downward in front of the tragus to the angle of the jaw, and 
thence forward to a point just posterior to the facial artery. Raise this flap 
of skin and superficial fascia as far as the anterior border of the masseter 
and turn it forward. Expose Stenson's duct and edge of the parotid gland 
(sufficiently to guard them). Divide the masseter and overlying deep fascia 
down to the bone in a transverse direction, and between Stenson's duct above 
and the highest branch of the facial nerve below. Free the muscle from 



SURGICAL ANATOMY OF LINGUAL NERVE. 193 

the bone at the sigmoid notch and just below. Apply the trephine so as 
to leave a slight bridge of bone between the sigmoid notch and the trephine- 
opening — and subsequently cut this bridge away with bone-forceps. Expose 
the inferior dental nerve and artery — ligate the artery and also the internal 
maxillary artery (upon the external pterygoid muscle) if necessary. Secure 
the nerve with silk ligature, and, by traction on silk, follow the nerve to the 
foramen ovale, retracting the external pterygoid upward (or divide it). Sever 
the nerve as high and as low as possible. The lingual nerve, lying further 
forward and inward, may be also reached at the same time. (2) The entrance 
to the inferior dental canal may also be reached from the inner aspect of the 
inferior maxilla — by making an incision around the angle of the jaw, corre- 
sponding with the insertion of the masseter, and raising the soft parts from 
the inner surface of the bones subperiosteally to the dental foramen — the 
mouth cavity not being opened (Liicke-Sonnenburg operation). (3) The 
operation of exposing the inferior dental nerve through the mouth is to be 
preferred, as being less disfiguring — although probably more difficult. 



EXPOSURE OF INFERIOR DENTAL NERVE AT MENTAL FORAMEN, 
FROM WITHIN MOUTH. 

Description. — The lower lip is everted and an incision made over the 
site of the mental foramen. 

Position. — Patient supine; head supported and to one side. Surgeon 
on side of operation, or on right for both operations. Assistant draws lower 
lip well downward. 

Landmarks. — A line drawn over the supraorbital foramen and between 
the two bicuspids of both jaws will cross the infraorbital and mental foramina 
— the mental foramen, in the adult, generally lying midway between the upper 
and lower borders of the jaw proper (exclusive of teeth). 

Incision. — Transverse, through mucous membrane along line of its 
reflection from lower lip to inferior maxilla, with its center between the two 
bicuspids, the lower lip being firmly drawn downward. A vertical incision 
may be made instead of the transverse. 

Operation. — This incision passes through periosteum to bone, upon 
slight downward freeing of which the nerve is found emerging from the 
mental foramen. 

Comment. — An incision could be made from without, through the 
tissues of the chin, over the position of the foramen, in the direction of the 
fibers of the facial nerve, if the matter of scarring be not taken into account. 



SURGICAL ANATOMY OF LINGUAL (GUSTATORY) NERVE. 

Description and Relations. — A nerve of common sensation — branch 
of posterior division of inferior maxillary nerve. Descends under external 
pterygoid, to inner side and anterior to dental nerve, a cord generally con- 
necting the two, and being joined near origin by chorda tympani. The 
nerve then passes between internal pterygoid muscle and ramus of lower 
jaw — inclining inward to side of tongue, and, passing over attachment of 
superior constrictor of pharynx to the lower jaw and the styloglossus muscle, 
above the deep part of submaxillary gland, is continued forward between 
mucous membrane of mouth and mvlohvoid muscle and lies on its origin 
13 



194 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

close to bone — then runs between mylohyoid and hyoglossus — crosses below 
Wharton's duct, and passes along side of tongue, under mucous membrane, 
to apex. 

Comment. — On widely opening the mouth, one can feel the pterygo- 
maxillarv ligament, as a prominent ridge behind the last molar. The nerve 
is generally to be felt behind the ptervgomaxillary ligament, about 1.3 cm. 
(\ inch) posterior and inferior to the last molar, lying just beneath the mucous 
membrane. 



EXPOSURE OF LINGUAL (GUSTATORY) NERVE IN THE MOUTH. 

Position. — Patient on back; head slightly raised; gag in opposite side 
of mouth; cheek of operated side held open by retractors; tongue of patient 
drawn out and to opposite side by assistant. Surgeon stands on patient's 
right for both operations, and uses a head-mirror. 

Landmarks. — Ramus of jaw; pterygomaxillary ligament; last molar 
tooth. 

Incision. — Vertical, about 2.5 cm. (1 inch) in length, placed in fold of 
mucous membrane midway between tongue and gum, with center on level 
with last molar. The nerve lies about at the junction of the upper and 
middle thirds of a line from the crown of the last molar to the angle of the 
jaw. 

Operation. — Having incised in the above line, the nerve is found just 
beneath the mucous membrane, prior to dipping under the mylohyoid muscle 
— and is isolated and drawn forward by a hook. 

Comment. — The lingual nerve may be reached from outside the mouth 
by excising a part of the inferior maxilla, at the junction of the alveolar process 
and the ascending ramus (Loebker). Or it may be reached by dissecting 
up under the internal surface of the inferior maxilla, displacing the sub- 
maxillary gland, dividing the posterior portion of the mylohyoid and finding 
the nerve under the posterior portion of the sublingual gland (Luschka). 



SURGICAL ANATOMY OF FACIAL NERVE. 

Description. — Arises, superficially, at upper end of medulla oblongata, 
in groove between olivary and restiform bodies — passes, in company with 
auditory nerve-, forward and outward to internal auditory meatus, which it 
enters with auditory nerve, the pars intermedia intervening between the 
nerves. At the bottom of meatus, the facial nerve enters aqueductus Fallopii, 
which it follows to its emergence at the stylomastoid foramen — thence passes 
downward and forward through substance of parotid gland — crosses external 
carotid artery and divides behind ramus of inferior maxilla, opposite upper 
margin of digastric muscle, into two chief branches: — (1) Temporofacial, 
running upward and forward through parotid gland, crossing external carotid 
artery and temporomaxillary vein and passing over neck of condyle of jaw, 
and dividing into temporal, malar, and infraorbital branches, — and (2) 
Cervicofacial, running downward and forward, through parotid gland, 
crossing external carotid artery, and dividing, opposite angle of jaw, into 
buccal, supramaxillary, and inframaxillary branches. 



EXPOSURE OF SPINAL ACCESSORY NERVE. 1 95 

EXPOSURE OF FACIAL NERVE IN FRONT OF MASTOID PROCESS. 

BAUM'S OPERATION'. 

Position. — Patient supine; head elevated and to one side. Surgeon to 
right for both operations. 

Landmarks. — Anterior border of mastoid process; posterior border of 
ascending ramus of inferior maxilla. The point at which the nerve is sought 
being from 6 mm. to 1.3 cm. (J to \ inch) in front of center of anterior border 
of mastoid process. 

Incision. — Begins close behind pinna of ear, opposite meatus — passes 
downward to opposite lobule of ear, and then downward and forward almost 
to angle of inferior maxilla. 

Operation. — This incision is deepened through skin and fascia, with 
care. The parotid fascia is incised and the parotid gland is retracted forward. 
The anterior edge of the sternomastoid is exposed and drawn backward. 
The posterior belly of the digastric is exposed and the nerve is sought on a 
line with the upper border of the posterior belly of this muscle and at the 
point above mentioned — coming from the stylomastoid foramen toward the 
surface. The posterior auricular artery and vein will probably need ligating, 
and some fibers of the great auricular nerve will be cut. The internal jugular 
vein is near the deep part of the wound, but there are no other important vessels 
anterior to the plane of the digastric (behind which is the external carotid). 
If necessary, especially in stout subjects, a small transverse incision, passing 
forward from below the pinna, may be added. 



SURGICAL ANATOMY OF SPINAL ACCESSORY NERVE. 

Description and Relations. — (i) Accessory portion passes outward to 
jugular foramen, where it unites with spinal portion, and is joined to upper 
ganglion of the vagus and sends fibers into its pharyngeal and superior laryn- 
geal branches and into the trunk of that nerve below the ganglion. (2) 
Spinal portion, after issuing from jugular foramen (where it unites with 
accessorv portion), passes backward, crossing in front of (sometimes behind) 
the internal jugular vein, descends obliquely behind digastric and stylo- 
hyoid muscles and occipital artery to enter upper third of sternomastoid 
about 5 cm. (2 inches) below tip of mastoid process — perforates this muscle 
in its second fourth and emerges on level with center of its posterior border 
— and runs thence obliquely across the occipital triangle, and, entering 
upper part of lower third of its anterior border, terminates in the deep surface 
of the trapezius. 



EXPOSURE OF SPINAL ACCESSORY NERVE AT ANTERIOR BORDER 
OF STERNOMASTOID MUSCLE. 

Position.— Patient supine; shoulders slightly elevated; head to opposite 
side; neck supported. Surgeon on right, for either operation. 

Landmarks. — Anterior border of upper portion of sternomastoid. 

Incision. — About 7.5 cm. (3 inches) in length, following the anterior 
border of the sternomastoid, with its center opposite a point about 5 cm. 
(2 inches) below the tip of the mastoid process. 

Operation. — Having cut through skin and superficial fascia, and opened 



196 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



up the cervical fascia, avoiding the external jugular vein and great auricular 
nerve, expose the anterior border of the sternomastoid and draw the muscle 
firmly backward. Recognize the inferior border of the posterior belly of 

the digastric — the nerve will be found pass- 
ing from beneath it to the sternomastoid, 
crossing the transverse process of the atlas. 
Avoid branches of the facial nerve (at the 
upper edge of the wound) and the occipital 
artery (lying over the nerve). 

Comment. — If only that portion of the 
spinal accessory be involved which is distal 
to the sternomastoid, the nerve may be ex- 
posed by an incision placed along the poste- 
rior border of the sternomastoid, with its 
center opposite the center of the posterior 
border of the muscle. 



FACIO-ACCESSORY OR FACIO-HYPOGLOS- 

SAL ANASTOMOSIS FOR PERIPHERAL 

FACIAL PARALYSIS. 

Description. — The operation consists in 
anastomosing the paralyzed facial nerve with 
some neighboring intact nerve. The anasto- 
mosis is usually made with either spinal ac- 
cessory or the hypoglossal. While each 
method has its advantages and disadvant- 
ages — and each method its adherents — it 
would seem that the greater advantages lie 
in favor of severing the spinal accessory 
nerve, and uniting its central end to the 
impaired peripheral end of the facial. The 
glossopharyngeal has also been used. 

Position. — Patient supine; shoulders 
slightly elevated; head to opposite side; 
neck supported. Surgeon on side of oper- 
ation. 

Landmarks. — Anterior border of sterno- 
mastoid muscle; mastoid process; upper bor- 
der of thyroid cartilage. 

Incision. — Along the anterior border 
of the sternomastoid — beginning 2 cm. 
(about I inch) above the tip of the mastoid process — and ending opposite 
the upper border of the thyroid cartilage. 

Operation. — (1) To Expose the Facial Nerve; — Having incised through 
skin and fascia, the sternomastoid is exposed and retracted posteriorly, and 
the parotid gland exposed and displaced anteriorly. The nerve is sought 
as it emerges from the gland at a point approximately 1 cm. (about J inch) 
above, and 1 cm. (about J inch) internal to the tip of the mastoid process. 
Just distal to the point selected for division, which should be as near the 
stylomastoid foramen as possible, two fine silk sutures should be carried through 
the sheath of the nerve, after which the nerve is divided (Fig. 165). (2) 




Fig. 165. — F acid-accessory An- 
astomosis: — A, Mastoid process; B, 
Parotid gland; C, Sternomastoid 
muscle; D, Stylohyoid and posterior 
belly of digastric muscles; E, E, Di- 
vided ends of facial nerve; F, Spinal 
portion of spinal accessory nerve; G, 
Divided end of spinal accessory anasto- 
mosed with distal end of facial nerve. 
(Modified from Berger and Hart- 
mann.) 



EXPOSURE OF POSTERIOR DIVISIONS OF CERVICAL NERVES. 197 

To Expose the Spinal Accessory Nerve; — The nerve enters the deep surface 
of the sternomastoid about 5 cm. (2 inches) below the mastoid process. It is 
covered by the posterior belly of the digastric and the deep fascia, and lies 
just below the transverse process of the atlas. Here also two fine silk sutures 
are passed through the sheath of the nerve just proximal, in this case, to the 
line where the nerve is to be divided. The nerve is then divided transversely, 
with a sharp knife (and not with scissors, which also crush) — and is dissected 
up sufficiently to enable it to reach the severed distal end of the facial without 
tension — and here the facial and spinal accessory stumps are united end-to- 
end by means of fine silk interrupted sutures passing through their sheaths 
only. The spinal accessory may be used in three ways — the entire nerve 
may be taken; the branch to the trapezius may be used; or the trunk may be 
split and one of the split portions be employed. (3) To Expose the Hypo- 
glossal Nerve; — This is accomplished through the same incision. The pos- 
terior belly of the digastric lies just above the nerve, which is isolated as it runs 
forward from under the occipital artery to cross the external carotid. The 
technic of anastomosis is carried out as in the above instance. 



EXPOSURE OF POSTERIOR DIVISIONS OF FIRST, SECOND, AND 
THIRD CERVICAL NERVES. 

KEEN'S OPERATION. 

Description. — The posterior divisions of the first, second, and third 
cervical nerves have been exposed and excised in spasmodic torticollis- 
supplying, as they do, the posterior rotator muscles of the neck. 

Position. — Patient turned to one side; neck made prominent. Surgeon 
at patient's back. 

Landmarks. — Middle line of neck; external occipital protuberance. 

Incision. — From 6 to 7.5 cm. (2^ to 3 inches) in length and transverse 
in direction — passing outward from the middle line of the neck, at a point 
about 4 cm. (1^ inches) below the external occipital protuberance. 

Operation. — Divide, in the line of incision, the skin, fascia, trapezius, 
and posterior border of the splenitis capitis, until the complexus is reached, 
after which the nerves are separately isolated: — (1) Find the occipitalis major 
nerve (internal branch of posterior division of second cervical nerve) emerging 
from the complexus and about to enter the trapezius. Divide the complexus 
transversely, on a level with the nerve. Follow the nerve to the common 
trunk of the posterior division (before the external and internal branches 
are given off). Thus the second cervical nerve is exposed. (2) Recognize 
the suboccipital triangle, — bounded, above and internally, by the rectus 
capitis posticus major (from spinous process of axis to superior curved line 
of occiput), — above and externally, by obliquus capitis superior (from upper 
surface of transverse process of atlas to occipital bone, between curved lines, 
and external to complexus), — below and externally, bv obliquus capitis 
inferior (from apex of spinous process of axis to lower and back part of trans- 
verse process of atlas). Within this triangle lies the suboccipital nerve 
(posterior division of first cervical nerve), which does not divide into internal 
and external branches — lying close to the occiput and behind the vertebral 
artery. Trace it as near to the spine as possible. Thus the first cervical 
nerve is exposed. (3) The external branch of the posterior division of 
the third cervical nerve is found about 2.5 cm. (1 inch) lower down than 
the occipitalis major and upder the complexus. It is to be followed 



198 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

to the common trunk of the posterior division. And thus the third cervical 
nerve is exposed. 

Comment. — This operation has been modified by making a vertical 
incision from the occiput downward, about 4 cm. (1^ inches) outside of 
the median line — passing through the trapezius, edge of the splenius, and 
then through the complexus. Also, the second and third divisions may be 
divided without the first. 



SURGICAL ANATOMY OF BRACHIAL PLEXUS OF NERVES. 

Formed by. — Fasciculus from anterior branch of fourth cervical, anterior 
branches of fifth, sixth, seventh, and eighth cervical, and greater part of 
anterior branch of first dorsal. 

Extent and Position. — From lower part of side of neck to lower part 
of axillary space, dividing, opposite the coracoid process, into numerous 
trunks, and giving off its terminal nerves at the lower axillary boundary, 

Relations. — (1) In neck : — First, lies between anterior and middle 
scaleni and at outer border of former muscle; — then parti}- behind and partly 
above and external to third part of subclavian artery, in the posterior triangle 
of neck, crossed by posterior belly of omohyoid; — then behind clavicle and 
subclavius muscle, upon first serration of serratus magnus and subscapularis 
muscles. (2) In axilla : — Lies to outer side of first portion of axillary artery, 
being covered by pectoralis major — then surrounds second portion of artery, 
covered by the pectoralis minor and resting upon subscapularis muscle, one 
cord lying to inner side, one behind, and one to outer side of vessel. The 
third part of the artery has the internal cutaneous and inner head of median 
nerve in front; circumflex and musculospiral behind; ulnar and lesser internal 
cutaneous on inner side; and trunk of median and musculocutaneous on 
outer side. 



EXPOSURE OF BRACHIAL PLEXUS IN NECK. 

Position. — Patient upon back, near edge of table; thorax raised; head 
extended and turned to opposite side; arm drawn downward and behind 
back. Surgeon stands in front of right shoulder, in operating upon either 
side. 

Landmarks. — Sternomastoid ; trapezius. 

Incision. — Vertical, in posterior triangle of neck — beginning about 9 
cm. (3^ inches) above clavicle and passing downward to within about 1.3 
cm. (J inch) of middle of clavicle, parallel with anterior border of trapezius, 
but nearer posterior border of sternomastoid. 

Operation. — Having divided skin and platysma, the external jugular 
vein is either ligated and cut between two ligatures, or retracted. Some of 
the descending branches of the cervical plexus are apt to be incised, generally 
the supraclavicular. Incise the deep cervical fascia. Recognize the outer 
border of the anterior scalenus and retract inward. Retract the posterior 
belly of the omohyoid downward and expose the brachial plexus by dissection. 
Avoid the transversalis colli artery and vein crossing the middle of the plexus. 
Identify the cords of the plexus by following with finger to the interval between 
the anterior and middle scalenus muscles. 



OPERATION FOR BRACHIAL BIRTH PALSY. 



199 



OPERATION FOR BRACHIAL BIRTH PALSY. 

Description. — The brachial plexus as a whole, or its constituent roots 
individually, is subject to the injuries which may involve nerve structures in 
general, resulting in a partial or general paralysis. A special form of paralysis, 
termed brachial birth palsy, is especially apt to occur at birth in those cases 
where the head and neck have been forced away from the shoulder, thus 
overstretching or lacerating nerve-roots of the brachial plexus, especially the 
upper roots. This subject has been extensively and creditably worked up 
by Clark, Taylor, and Prout, through whose courtesy the following writing is 
taken from Keen's " Surgery," Vol. II. 

"One of the most common and interesting forms of brachial palsy are 
the brachial birth palsies, usually of the upper arm type, very rarely the total 




Fig. 166. — Dissection* of the Operative Field in Brachial Birth Palsy (Clark, 
Taylor, and Prout): — A, Scalenus amicus muscle; B, Phrenic nerve; C, Internal jugular vein; 
D, Transversalis colli artery, divided; E, \'II Cervical root; F, Omohyoid muscle; G, V Cervical 
root; H, Scalenus medius muscle; I, VI Cervical root; J, Transversalis colli artery; K, Supra- 
scapular nerve; L, Nerve to subclavian muscle; M, Clavicle; N, Nerve to scalenus anticus muscle. 

arm palsy. They may occur in either vertex or breech presentation, when 
traction is exerted and the head pulled away from the shoulder. The attitude 
is very characteristic in severe cases; the arm hangs limp by the side, as it 
cannot be abducted at the shoulder or flexed at the elbow, and, as it cannot be 
rotated out at the shoulder or supinated in the forearm, the whole arm is 
rotated in and the hand is pronated so that it looks backward and sometimes 
even outward. They should be operated on as described below. Kennedv 
and Taylor have reported several operations with good results, and among 
them were cases ten and eleven years old. In mild cases nothing is required 
except massage, passive motion, electricity, and apparatus — and in all cases, 
unless there is neuritis, these measures should be faithfully employed until 
recovery results or it becomes necessary to operate. When there is neuritis, 
complete rest in the normal position is demanded until inflammation has 
subsided. The only treatment for cases of permanent paralysis is the excision 



200 OPERATIONS UPON THE XERXES, PLEXUSES, AND GANGLIA. 

of the scar tissue replacing and surrounding the injured nerve and suture of 
the freshened nerve-ends. The time at which to undertake this treatment 
is still a matter of dispute. Kennedy advises early operation — in two or three 
months if the muscles give no response to the faradic current. If the muscles 
re-pond and continue to improve in response to the faradic current, he does 
not operate but expects spontaneous recovery. Taylor advises delay for 
a year in most cases of brachial birth palsies. The advantages of this delay 
are a more definite localization of the lesion, larger size of the field of operation, 
and diminished danger from shock and hemorrhage. 




Fig. 167. — Dissection of the Operative Field in Brachial Birth Palsy (Clark, 
Taylor, and Prout): — A, Phrenic nerve; B, Scalenus anticus muscle; C, Internal jugular vein; 
D, Transversalis colli artery; E, Omohyoid muscle, divided; F, Suprascapular artery, divided; 
(j, YIII Cervical and I dorsal roots; H, External anterior thoracic nerve; I, Subclavian artery; 
J, V Cervical root; K, VI Cervical root; L, Scalenus medius muscle; M, Nerve to scalenus anticus 
muscle; X, Suprascapular nerve; O, Transversalis colli artery; P, VII Cervical root; Q, Omo- 
hyoid muscle, divided; R, Suprascapular artery; S, Clavicle and subclavius muscle, divided and 
retracted; T, Deltoid, pectoralis minor, pectoralis major (muscles); U, Nerve to subclavius 
muscle. 



" The incision extends from the posterior border of the sternomastoid at 
the junction of its middle and lower third, to the junction of the middle and 
outer thirds of the clavicle through the skin, platysma, and deep fascia. The 
omohyoid muscle, exposed near the clavicle, with the suprascapular vessels 
beneath it, is retracted downward, or, if necessary, divided. Beneath the 
layer of fat at this level the deep fascia, usually thickened, covering the plexus 
is divided and dissected away from it. The injured portion of the nerve or 
nerves, determined beforehand from the paralysis, is felt to be thickened or 



EXPOSURE OF MEDIAN NERVE IN MIDDLE OF ARM. 201 

indurated. This area is excised by a sharp scalpel through healthy nerve- 
tissue and the ends sutured (Figs. 166 and 167). 

" This incision suffices for the common type where the lesion is confined 
to the fifth or fifth and sixth nerve-roots and their junction. When, however, 
the lesion extends to the lower roots of the plexus, or lies in the lower part of 
the plexus, the incision should be extended downward and the clavicle, sub- 
clavius muscle, and, if necessary, the pectoral muscles divided to give a 
better exposure. If thought best, the operation may be done in two stages 
to avoid too long an operation and too much shock. The clavicle is afterward 
sutured periosteally. An immobolizing dressing approximating the head 
and shoulder to relieve any tension on the plexus should be applied and this 
position maintained for two or three weeks. After-treatment by massage, 
electricity, and the use and education of the muscles is very important. The 
results of these operations have been very encouraging. The improvement 
is slow and continuous through a number of vears." 



SURGICAL ANATOMY OF MEDIAN NERVE. 

Description. — (a) In Arm; Arises by a root from inner and one from 
outer cords of brachial plexus, which embrace axillary artery, uniting either 
in front or to outer side of the vessel. Descends arm on outer side of brachial 
artery at first — then crosses in front of the middle of artery (though some- 
times passing behind) — thence downward on inner side of artery to elbow — 
where it is separated from elbow-joint by brachialis anticus muscle and is 
covered by bicipital fascia, (b) In Forearm; Passes between two heads of 
pronator radii teres and descends between flexor sublimis and profundus 
digitorum to about 5 cm. (2 inches) above the annular ligament of wrist, 
where it lies beneath the fascia, between the tendons of the flexor sublimis 
digitorum below, the palmaris longus internally, and the flexor carpi radialis 
externally (or rather more under the palmaris longus). (c) In Hand; It 
enters palm beneath the annular ligament and rests upon flexor tendons, 
covered by fascia and superficial palmar arch. 



EXPOSURE OF MEDIAN NERVE IN MIDDLE OF ARM. 

Position. — Patient's arm is extended and abducted, with hand supine. 
Surgeon stands on outer side of right limb, cutting from above downward; 
and between body and left limb, cutting from above downward (or on outside 
of left limb, cutting from below upward). 

Landmarks. — Inner edge of bicipital muscle. 

Incision. — Along inner edge of biceps, in middle of arm — about 4 cm. 
(2^ inches) in length. 

Operation. — Divide skin and connective tissue. Avoid internal cutaneous 
nerve and basilic vein. Clearly expose inner edge of biceps muscle and 
draw the muscle to the outer side, when the median nerve is found crossing 
the brachial artery from the outer toward the inner side (or sometimes passing 
beneath the artery). 



202 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



EXPOSURE OF MEDIAN NERVE AT BEND OF ELBOW. 

Position. — As above. 

Landmarks. — Groove between biceps and pronator radii teres muscles. 

Incision. — Between inner margin of biceps and outer margin of pronator 
radii teres, somewhat nearer the former, with center of incision opposite 
the fold of the elbow, and being about 5 cm. (2 inches) in length. 

Operation. — This incision will, in the usual disposition of the veins 
at the elbow, pass to the outer side and nearly parallel with the median basilic 
vein, which should be retracted inward. Incise the bicipital fascia in a line 
with the skin-cut. The median nerve lies just to the inner side of the brachial 
artery and its vena? comites — all lying upon the brachialis anticus. Gut- 
suture the bicipital fascia in closing the wound. 



SURGICAL ANATOMY OF ULNAR NERVE. 

Description. — (a) In Arm; Arises from inner cord of brachial plexus, 
between axillary artery and vein, and passes down arm on inner side of 
axillary and brachial arteries to middle of arm, covered only by skin and 
fascia — thence diverges to cross inner head of triceps obliquely — pierces 
interna] intermuscular septum and descends posterior to that structure, 
together with inferior profunda artery, which is upon its outer side, (b) 
At Elbow; Occupies groove between olecranon and internal condyle, resting 
upon posterior surface of latter (rarely upon anterior surface), and enters 
forearm between two heads of flexor carpi ulnaris. (c) In Forearm; Passes 
vertically down ulnar side, upon. flexor profundus digitorum, its upper half 
covered by flexor carpi ulnaris, its lower half by skin and fascia (the nerve 
here lying external to flexor carpi ulnaris). The ulnar nerve lies, throughout, 
to the ulnar side of the ulnar artery — the upper third lying considerably to 
the inner side, and the lower two-thirds near to the inner side. The dorsal 
cutaneous branch passes posteriorly between 5 and 7.5 cm. (2 and 3 inches) 
above the wrist, (d) At Wrist; Crosses front of annular ligament between 
ulnar artery and pisiform bone, a little internal and posterior to the artery, 
and immediately divides into superficial and deep palmar branches. 



EXPOSURE OF ULNAR NERVE ABOVE MIDDLE OF ARM. 

Position. — As for median nerve in middle of arm (page 201). 

Landmarks. — Brachial artery, which is parallel with and to outer side 
of the nerve for the upper half of the arm. 

Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with its center 
just above the middle of the arm — running parallel with and about 1.3 cm. 
(^ inch) to inner side of line of brachial artery (the line for the ligation of 
the middle third of the brachial artery passing along the inner margin of the 
biceps muscle). 

Operation. — Incise skin and fascia, which here alone cover the nerve. 
Avoid the basilic vein and the vena? comites of the brachial artery — also the 
internal cutaneous nerve to the outer, and the lesser internal cutaneous nerve 
to the inner side. The ulnar nerve is found diverging from its course parallel 
with the inner side of the brachial artery to pass obliquely across the inner 
head of the triceps to pierce the internal intermuscular septum. 



EXPOSURE OF MUSCULOSPIRAL NERVE. 203 

EXPOSURE OF ULNAR NERVE JUST ABOVE INTERNAL CONDYLE OF 

HUMERUS. 

Position. — Patient upon back at edge of table. Assistant stands on 
side opposite one to be operated, and, grasping patient's wrist, with patient's 
hand prone, draws his (patient's) arm and forearm across the chest, thus 
exposing its posterior surface to the operator — who stands upon the side to 
be operated, cutting from elbow toward shoulder on both sides. 

Landmarks. — Olecranon; internal condyle of humerus. 

Incision. — About 5 cm. (2 inches) in length, extending from a point 
about 1.3 cm. (h inch) above (to proximal side of) internal condyle and midway 
between internal condyle and olecranon, upward toward a point at inner 
side of brachial artery opposite the insertion of the coracobrachialis muscle 
(about center of arm). 

Operation. — Incise skin and fascia in above line — when the nerve will 
be found upon the posterior surface of the internal intermuscular septum, 
with the inferior profunda artery upon its outer side. 

Comment. — If the incision were to extend over the internal condyle, 
the nerve would be found lying upon the posterior surface of the base of the 
inner condyle of the humerus, close to the bone and along the inner edge 
of the triceps. 



SURGICAL ANATOMY OF MUSCULOSPIRAL NERVE. 

Description. — Arises, in common with circumflex nerve, from posterior 
cord of brachial plexus — descends arm behind axillary and brachial arteries 
and in front of tendons of latissimus dorsi and teres major, and winds around 
humerus in musculospiral groove, from inner to outer side, with superior 
profunda artery, lying between the internal and external heads of the triceps. 
Arriving at outer side of arm, it pierces the external intermuscular septum 
about midway between insertion of deltoid and tip of external condyle (namely, 
at lower third) and descends between supinator longus and brachialis anticus 
to front of external condyle, where it divides into radial and posterior inter- 
osseous nerves. 



EXPOSURE OF MUSCULOSPIRAL NERVE BELOW MIDDLE OF ARM. 

Description. — The exposure is here made upon the external aspect of 
the arm and the nerve is reached anterior to the external intermuscular 
septum. 

Position. — Same as for ulnar nerve just above internal condyle (page 
203). The surgeon may also stand so as to cut from shoulder toward elbow. 

Landmarks. — Insertion of deltoid (about middle of arm); external 
condyle of humerus; upper border of supinator longus. 

Incision. — About 6 to 7.5 cm. (2% to 3 inches) in length — crossing obliquely 
the outer surface of the lower third of the arm — so placed that its center 
will be midway between the deltoid and the external condyle — and so that 
its obliquity will follow the line of the upper border of the supinator longus. 

Operation. — Having incised skin and fascia, avoiding cephalic and 
median cephalic veins, identify the internal border of the supinator longus. 
Draw this muscle to the outer side, so as to expose the interval between it 



204 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

and the brachialis anticus — where the nerve will be found close to the bone, 
accompanied by a branch of the superior profunda artery. 

Comment. — Exposure of the nerve at its bifurcation into radial and 
posterior interosseous may be accomplished (if not performed as a separate 
operation) by continuing the above incision downward. 



SURGICAL ANATOMY OF THE INTERCOSTAL NERVES. 

Description. — (a) Pectoral Intercostal Nerves : — Pass outward, as 
the anterior divisions of the dorsal nerves, in front of superior costotransverse 
ligaments, levatores costarum, external intercostal muscles, covered (to angle 
of ribs) by pleura and endothoracic fascia. They then approach upper 
part of each intercostal space to accompany intercostal vessels, in groove of 
rib above, to front of chest — the nerve lying below the vessels. Between 
angle of rib and middle of rib they lie between internal and external inter- 
costal muscles, giving off, a little posterior to middle of the ribs, the lateral 
cutaneous branches — which latter branches pass through external intercostal 
and serratus magnus muscles about center of ribs and divide into anterior 
and posterior branches. The main trunk of the intercostal nerve continues 
forward among fibers of internal intercostal muscles to costal cartilages — ■ 
thence passes between internal intercostal muscles and pleura, crossing in 
front of internal mammary artery and triangularis sterni muscle — to pierce 
internal intercostal muscles and pectoralis major and end in the anterior 
cutaneous branches, (b) Abdominal Intercostal Nerves : — Take the same 
course (as the anterior divisions of the dorsal nerves) as the pectoral inter- 
costals, from their origin to ends of intercostal spaces in which they lie — 
thence they run between the slips of origin of diaphragm to enter the abdominal 
wall, each nerve (from seventh to ninth, inclusive) crossing behind cartilage 
of rib below. In the abdominal wall they pass between internal oblique 
and transversalis, diverging from each other as they go forward, to outer 
edge of the rectus — and, piercing posterior layer of rectal sheath, rectus itself, 
and anterior layer of sheath, they supply rectus and sheath and end in the 
anterior cutaneous nerves near the linea alba. 

Comment. — (i) The exceptions in the distribution of the anterior divi- 
sions of the first, second, and twelfth nerves are not mentioned in the above 
descriptions. (2) The upper six dorsal nerves form the pectoral intercostal 
nerves — the lower six, the abdominal intercostals. (3) The final distribution 
of the lower dorsal nerves is as follows; — sixth, to pit of stomach; seventh, to 
lower end of ensiform cartilage; eighth, over the middle linea transversa; 
tenth, to the umbilicus; twelfth, midway between umbilicus and pubis. 

EXPOSURE OF INTERCOSTAL NERVE BETWEEN ANGLE AND MIDDLE 

OF RIB. 

Position. — Patient on side. Surgeon either in front or at back of patient. 

Landmarks. — Angle and lower border of rib. 

Incision. — Parallel with and just below lower border of rib, and lying 
between the angle and middle of rib. 

Operation. — Having incised skin, fascia, and external intercostal muscle, 
separate the cut edges of the external intercostal muscle and seek for nerve 
in the intermuscular plane between external and internal intercostals, near 
the lower border of the rib above. The nerve may be drawn down into view 
from the groove in the lower border of the rib by means of a nerve-hook. If 



SURGICAL ANATOMY OF GREAT SCIATIC NERVE. 205 

necessary, bite out a half-button of rib subperiosteally with rongeur forceps, 
fully exposing the nerve and intercostal vessels, when the latter may be 
divided between ligatures, if necessary. 

SURGICAL ANATOMY OF ANTERIOR CRURAL NERVE. 

Arises from second, third, and fourth lumbar nerves and descends through 
fibers of psoas muscle — emerging from lower part of its outer border, and 
descending beneath Poupart's ligament into thigh, beneath the iliac fascia, 
in groove between psoas and iliacus, being separated from femoral artery 
on its inner side by the psoas. It divides below Poupart's ligament into an 
anterior division, passing in front of the external circumflex vessels — and a 
posterior division, passing behind these vessels. 

EXPOSURE OF ANTERIOR CRURAL NERVE, BELOW POUPART'S 

LIGAMENT. 

Position. — Patient on back; limb extended and rotated slightly outward. 
Surgeon to outer side of right limb, and to inner side of left or on right, 
leaning over body; or on outer side of left limb, cutting from below up- 
ward). 

Landmarks. — Middle of Poupart's ligament. 

Incision. — Vertical, about 5 cm. (2 inches) in length, carried downward 
from a point about 1.3 cm. (h inch) external to center of Poupart's ligament. 

Operation. — Incise skin and superficial fascia. Crural branch of genito- 
crural nerve may be met running down the thigh. The superficial circumflex 
iliac vessels will lie across the incision. Flex the thigh to relax the muscles. 
The nerve will be found lying to the outer side of the femoral artery, in the 
groove between the iliacus and psoas muscle-. 

EXPOSURE OF OBTURATOR, SUPERIOR GLUTEAL. AND PUDIC 

NERVES. 

The operations for the exposure of the obturator nerve at the thyroid 
foramen, the superior gluteal nerve upon the buttock, the pudic nerve upon 
the buttock, and the pudic nerve in the perineum, are. practically, the same 
as the operations for the ligation of the obturator artery at the thyroid foramen, 
the gluteal artery upon the buttock (page 87), the internal pudic artery upon 
the buttock (page 87), and the internal pudic artery in the perineum (page 
87), respectively. 

SURGICAL ANATOMY OF GREAT SCIATIC NERVE. 

Description. — Continuation of lower cord of sacral plexus — leaves pelvis 
by great sacrosciatic foramen, below pyriformis — descends from hollow 
between great trochanter and tuberosity of ischium down back of thigh, to 
about its lower third, where it divides into external and internal popliteal 
nerves (the division often occurring higher). The great sciatic nerve rests, 
from above downward, upon the ischium, gemellus superior, obturator 
internus, gemellus inferior, quadratus femoris and adductor magnus, — and 
is covered by, from above downward, the skin, fascia, gluteus maximus, 
biceps, and small sciatic nerve. It has the sciatic artery to its inner side, 
and small sciatic nerve superficial to it above, and to its inner side as it (the 
small sciatic nerve) descends the thigh. 



2o6 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



EXPOSURE OF GREAT SCIATIC NERVE AT LOWER BORDER OF 
GLUTEUS MAXIMUS. 

Position. — Patient turned upon side sufficiently to expose field of opera- 
tion. Surgeon on side of operation, cutting downward on left side, and 
upward on right. 

Landmarks. — Lower margin of gluteus, which is below fold of buttock; 
tuberosity of ischium; great trochanter. 

Incision. — Begins over gluteal fold and passes vertically downward for 
a distance of 7.5 to 10 cm. (3 to 4 inches), with center of incision over lower 
margin of gluteus maximus and placed midway between tuberosity of ischium 
and great trochanter — although the nerve lies a' little nearer the former than 
the latter, for by this incision the hamstring muscles are more easily retracted. 

Operation. — Having incised skin and fatty areolar tissue, the small 
sciatic nerve and cutaneous vessels are encountered. Expose the lower edge 
of the gluteus maximus, running downward and outward, and retract upward. 
Find and retract the hamstring muscles inward, bending the knee to aid the 
retraction. The nerve is found a little nearer the tuberosity of the ischium 
than the great trochanter and under the outer edge of the biceps muscle. 



SURGICAL ANATOMY OF INTERNAL POPLITEAL BRANCH OF GREAT 

SCIATIC NERVE. 

Description. — The larger branch of the great sciatic. Extends from 
bifurcation, at lower third of thigh, through middle of popliteal space to 
lower border of popliteus muscle, where it becomes the posterior tibial nerve. 
It is covered, above, by hamstring muscles; in the middle, by skin and fascia; 
and below, by heads of gastrocnemii. The popliteal vein intervenes between 
the nerve superficially, and the artery deeply. In the upper popliteal space 
the nerve lies external to the popliteal artery and vein; at the level of the 
knee, the nerve crosses these vessels; and in the lower popliteal space the 
nerve lies to the inner side of the vessels. 



EXPOSURE OF INTERNAL POPLITEAL NERVE AT LOWER PART OF 

POPLITEAL SPACE. 

Position. — Patient rests on shoulder and side of chest, as nearly prone 
as anesthesia will allow; limb extended. Surgeon to outer side of left, cutting 
downward; and to inner side of right, cutting downward (or to outer side, 
cutting upward). 

Landmarks. — Heads of gastrocnemii muscles. 

Incision. — Begins opposite the center of the popliteal space and passes 
vertically downward for about 9 cm. (3^ inches), between the two heads of 
the gastrocnemii. 

Operation. — Having divided skin and superficial fascia, avoid external 
saphenous vein and nerve at the outer and lower part of the wound. Expose 
the heads of the gastrocnemii and open up, by blunt dissection, the interval 
between them, retracting the heads of the muscle to their respective sides. 
The nerve will be found the most superficial of the important structures in 
the popliteal space. 



EXPOSURE OF EXTERNAL POPLITEAL NERVE. 207 

SURGICAL ANATOMY OF POSTERIOR TIBIAL NERVE. 

Description. — The direct continuation of internal popliteal nerve. 
Extends from lower border of popliteus muscle to interval between internal 
malleolus and heel, where it divides into internal and external plantar nerves. 
It is covered, above, by gastrocnemius, plantaris, soleus, and intermuscular 
deep fascia; and, below, by only skin and fascia. It rests upon (its anterior 
relations are), above, tibialis posticus; and, below, flexor longus digitorum. 
It lies to inner side of posterior tibial artery above, but soon crosses it and 
runs on its fibular side to ankle. 



EXPOSURE OF POSTERIOR TIBIAL BETWEEN ORIGIN AND ANKLE. 

The operation for the exposure of the posterior tibial nerve at its origin 
is, practically, the same as that for the exposure of the internal popliteal at 
the lower part of the popliteal space (page 206). The posterior tibial nerve 
in the leg may be exposed by the same operation as would expose the poste- 
rior tibial artery at the same level (pages 109 and no). 

EXPOSURE OF POSTERIOR TIBIAL NERVE BEHIND INTERNAL 

MALLEOLUS. 

Position. — Patient on back; knee flexed; leg resting on outer side. Sur- 
geon stands facing either foot, cutting from above downward. 

Landmarks. — Internal malleolus; tendo Achillis. 

Incision. — Curved, about 5 cm. (2 inches) in length, made about 1.3 
cm. (^ inch) behind and parallel with the internal malleolus, beginning just 
in front of tip of malleolus and extending upward in a line midway between 
internal malleolus and tendo Achillis. 

Operation. — Directing the knife toward the tibia, divide skin, superficial 
fascia, and annular ligament. The order of the structures met behind the 
internal malleolus, from within outward, is, tibialis posticus; flexor longus 
digitorum; posterior tibial artery, vein and nerve; flexor longus hallucis. 
The nerve is therefore sought between the tendons of the flexor longus digi- 
torum and flexor longus hallucis. 



SURGICAL ANATOMY OF EXTERNAL POPLITEAL (PERONEAL) 
BRANCH OF GREAT SCIATIC. 

Description. — Smaller branch of great sciatic. Enters superior angle 
of popliteal space and passes obliquely along outer side of this space to head 
of fibula, lying near inner border of biceps (lying beneath skin and fascia, 
behind head of fibula, to inner side of biceps tendon). The nerve leaves 
the popliteal space in interval between biceps tendon and outer head of 
gastrocnemius — winds around neck of fibula between bone and peroneus 
longus muscle — and, piercing origin of latter muscle, divides into anterior 
tibial, musculocutaneous, and recurrent articular nerves. 

EXPOSURE OF EXTERNAL POPLITEAL BEHIND TENDON OF BICEPS. 

Position. — Patient on uninvolved side, rolled into slightly prone position; 
leg extended. Surgeon stands facing back of patient's knee. 
Landmarks. — Tendon of biceps; head of fibula. 



208 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Incision. — About 4 to 5 cm. (i£ to 2 inches), along posterior edge of 
tendon of biceps, extending from over the prominence of the external condyle 
of the femur toward the posterior border of the head of the fibula. 

Operation. — Divide skin and deep fascia. Expose the biceps tendon. 
Flex the knee to relax the tendon and search for the nerve near the attachment 
of the biceps tendon to the head of the fibula, near the outer edge of the 
gastrocnemius. 



SURGICAL ANATOMY OF ANTERIOR TIBIAL BRANCH OF EXTERNAL 

POPLITEAL. 

Description. — One of the terminal branches of the external popliteal. 
Commences between fibula and peroneus longus — pierces septum between 
peronei and extensors — passing obliquely beneath extensor longus digitorum 
to forepart of interosseous membrane. Runs forward on interosseous mem- 
brane between extensor longus digitorum and tibialis anticus, in upper part 
of leg — and between tibialis anticus and extensor longus hallucis, lower 
down. Passes under anterior annular ligament and ends in front of bend 
of ankle in external and internal branches. The anterior tibial nerve reaches 
the fibular side of the tibial artery at the junction of the upper and second 
fourths of the leg, thence lies in front of the artery to the ankle, and thence 
generally lies to its outer side. 



EXPOSURE OF ANTERIOR TIBIAL NERVE NEAR ORIGIN. 

Position. — Patient supine and inclined to uninvolved side; hip slightly 
flexed and rotated inward, so that knee rests upon inner aspect. Surgeon 
stands behind either limb, cutting from above on the right, and from below 
on the left. 

Landmarks. — Outer tuberosity of tibia; head of fibula. 

Incision. — Begins opposite the most external part of the tibial tuberosity, 
and about 1.3 cm. (| inch) anterior to the head of the fibula, and passes 
downward for 5 to 7.5 cm. (2 to 3 inches). 

Operation. — Having incised skin and fascia, the intermuscular septum 
between peroneus longus and extensor longus digitorum is sought, running 
obliquely downward and forward, and is opened up by blunt dissection. 
The anterior tibial nerve (and also the musculocutaneous nerve) is found 
deep in this intermuscular interval, running downward and inward, below 
the fibular head and covered by the extensor longus digitorum (the musculo- 
cutaneous running vertically downward). 

Comment. — The anterior tibial nerve may be exposed at any point on 
the leg below its upper fourth, by the same operation as would expose the 
anterior tibial artery at the corresponding level (pages 104, 105, and 106). 



SURGICAL ANATOMY OF THE CERVICAL SYMPATHETIC GANGLIA 

AND CORD. 

Description. — The cervical portion of the gangliated cord lies deeply 
in the neck, embedded in the fascia between the muscles covering the front 
of the vertebral column behind, and the carotid sheath in front — and consists 
of three ganglia, together with the connecting cord: — (a) Superior Cervical 



TOTAL EXCISION OF CERVICAL SYMPATHETIC. 209 

Ganglion (largest) — lies opposite second and third cervical vertebrae (some- 
times, fourth and fifth) — rests upon rectus capitis anticus major, posteriorly, 
— has internal carotid artery and internal jugular vein, anteriorly, — and 
pneumogastric nerve, externally, (b) Middle Cervical Ganglion (sometimes 
wanting) — opposite sixth (or seventh) cervical vertebra — upon, or close to, 
where the cord crosses the inferior thyroid artery, (c) Inferior Cervical 
Ganglion — between base of transverse process of seventh cervical vertebra 
and neck of first rib, lying between subclavian and vertebral arteries. 



TOTAL EXCISION OF CERVICAL SYMPATHETIC GANGLIA AND CORD. 

JONNESCO'S OPERATION. 

Description. — -The cervical sympathetic ganglia and cord have been 
incised, partially excised, and totally excised — chiefly for exophthalmic goiter 
and epilepsy — and also in hysteria, chorea, tumors of the brain, and glau- 
coma. The cord and one or both upper ganglia of one or both sides have 
been removed, — or both upper ganglia of both sides, with intervening cords, 
— or both cords with all the ganglia of one or both sides. The removal of 
the cord and ganglia of one side will be described below. 

Position. — Patient supine; shoulders and head raised and latter turned 
to opposite side; neck, shaved, rests upon a narrow support (to render promi- 
nent). Surgeon to right, for both sides. 

Landmarks. — Mastoid process; posterior border of sternomastoid; 
clavicle. 

Incision. — Beginning opposite the posterior margin of the mastoid pro- 
cess, passes downward along the posterior border of the sternomastoid to 
just below the clavicle. 

Operation. — Incise skin, superficial fascia, and platysma. Divide the 
external jugular vein between two ligatures. Displace the sternomastoid 
inward (or it may be split longitudinally near its posterior border and the 
parts retracted laterally). Expose the common sheath of the vessels by blunt 
dissection. Lift the carotid sheath, unopened, upward and retract it inward 
— when the cervical cord and superior and middle cervical ganglia will be 
exposed, lying upon the prevertebral muscles. Having well retracted the 
structures to that side toward which most easily displaced, isolate the trunk 
of the cervical sympathetic near the center of the incision. Follow it up to 
the superior ganglion, divide the communicating branches of the ganglion 
with delicate scissors, and remove the ganglion with fine forceps. Practising 
slight traction upon the distal end of the trunk, trace the cord down to the 
middle ganglion, which is similarly removed — carefully guarding, throughout, 
all important adjacent structures. Continuing gentle traction upon the cord, 
just sufficient to follow it, trace the main trunk down behind the clavicle to 
the inferior ganglion. Guard the spinal accessory nerve in the upper part 
of the neck — the nerves of the cervical plexus in the middle of the neck — 
the thyroid and vertebral vessels, recurrent laryngeal and phrenic nerves 
and pleura in the lower part of the neck — and the thoracic duct on the lower 
left side. In closing the operation, approximate the separated muscles with 
buried gut sutures — and close the superficial wound in the usual manner, 
unless temporary drainage be indicated. 



CHAPTER V. 

OPERATIONS UPON THE BONES. 

OSTEOTOMY IN GENERAL. 

Definition. — Any division of bone by cutting instrument. 

Indications. — Deformities of bones and joints (such as result from 
congenital conditions) ; diseases of bones and joints, followed by weakening 
of bone and subsequent curvature or angularity; malunion following fracture; 
ankylosis. 

Varieties. — (a) Linear Osteotomy; Simple division of bone in its con- 
tinuity, by simple transverse, oblique or vertical section-line (e. g., linear 
osteotomy of neck or shaft of femur for faulty ankylosis), (b) Cuneiform 
Osteotomy; Removal of a wedge-shaped piece of bone in its continuity (e. g., 
cuneiform osteotomy for bent tibia), — or from, or including, one of its ends 
(e. g., cuneiform osteotomy of a joint for ankylosis), (c) Osteo-arthrotomy; 
Though not a distinct variety of osteotomy, may be considered as an inter- 
articular osteotomy, linear or cuneiform. 

General Manner of Performing Osteotomy as to the Instrument. 
—Osteotomy, in general, may be performed with an osteotome, an instrument 
ground evenly from both sides, and graded upon its blade to indicate depth 
of section, — with a chisel, an instrument beveled from one side only, and 
similarly graded upon handle, — or with a special saw. 

General Manner of Performing Osteotomy as to Method of Opera- 
tion. — (a) Open Method; in which the site of the bone-section is exposed 
to view by a preliminary operation, (b) Subcutaneous or Submuscular 
Method; in which the site of bone-section is reached through the smallest, 
simplest incision and the bone divided out of sight and by the sense of touch. 
Cuneiform osteotomy is nearly always done by the open method. Linear 
osteotomy may be done by the subcutaneous or by the open method — the 
former being more frequently done — the latter being preferable where the 
safety of the parts can be better preserved by first exposing them. Cuneiform 
osteotomy should be done subperiosteally where possible, and when not 
contraindicated (as by disease). Linear osteotomy should be done sub- 
periosteally when performed by the open method, if possible and not contra- 
indicated. Linear osteotomy is usually performed with an osteotome or a 
saw. Cuneiform osteotomy is generally done with a chisel (sometimes with 
a saw). 

Instruments Used in Osteotomy. — Rubber tourniquet; scalpels; 
tenotomy knives; hemostatic forceps; dissecting and toothed forceps; scissors, 
curved and straight, sharp and blunt; retractors; chisels, various sizes and 
widths; osteotomes, various sizes and widths; mallets, preferably of wood; 
saws, especially of the osteotomy type (with narrow blade and with cutting 
part only at end, and with blunt point and large handle), and also chain- 
saws, Gigli saws, and butcher saw; periosteal elevators, curved and straight; 
rugines; raspatories; blunt dissector; bone-holding forceps; bone-cutting 

2IO 



LIXEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. 211 

forceps; needles, straight and curved; needle-holder; chromic and plain 
gut; silkworm-gut and kangaroo tendon; bone-drills; silver wire; pegs and 
nails, ivory and metallic; sand-bag (for part to rest upon and dissipate the 
jar). 

Preparation of Patient. — The part shaved. 

Position. — The position of patient, surgeon, and assistant will be deter- 
mined by the special operation. 



LINEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. 

Steps of Operation Preparatory to Division of Bone.— Having ex- 
sanguinated the limb by elevation, followed by the application of a rubber 
tourniquet (which may generally be dispensed with), the portion of the limb 
involved is placed 
upon a sand-bag 
(previously damp- 
ened and covered 
with several layers 
of wet. sterilized tow- 
els, to prevent the fly- 
ing of dust), which 
forms a yielding bed 
into which the part 
may be moulded and 
in which it may re- 
ceive the jar of the 
blows from the mal- 
let. An incision, just 
long enough to ad- 
mit the osteotome or 
saw, is made over 
the site of the bone- 
section. The incision 
is as limited as pos- 
sible, and so placed 
as to reach the bone 
by the most direct 
and safest route, and 
with the least danger 
to important struc- 
tures. It should be, 
where possible, in a 
line with the over- 
lying muscle-fibers— 

should avoid vessels and nerves — and is generally parallel with the bone. 
This incision is usually made directly to the bone with one stroke — it being 
impossible, from the small size of the wound, to recognize the intermuscular 
planes, or the bone's exact level, if at any depth from the surface. Hav- 
ing made a path to the bone, the remaining steps of the operation will de- 
pend upon the instrument with which the division of the bone is to be made. 

Division of Bone with Osteotome. — Having made the incision through 




Fig. 1 6S.— Linear Osteotomy by the Sibcutaneois Method: 
— A. Linear osteotomy of anatomical neck of femur with saw; B, 
Linear osteotomy of surgical neck of femur with osteotome. 



212 OPERATIONS UPON THE BONES. 

the soft parts with a knife, the knife is not withdrawn but allowed to remain 
in situ as a guide — upon this an osteotome (somewhat narrower than the 
bone to be divided) is introduced, entering the wound with the length of its 
cutting edge corresponding to the length of the wound. It is carefully passed 
down, in contact with the knife, to the bone, and the knife withdrawn. The 
osteotome, constantly held in contact with the bone, is now turned with its 
cutting-edge in the direction of the desired bone-section (which is generally 
at a right angle to the incision of the soft parts). In the act of turning the 
osteotome into position, the soft parts are levered away by the blunt sides 
of the instrument, and the bone is hugged, but care is used not to detach 
the periosteum (which the knife-incision may have cut) (Fig. 168, B). The 
osteotome is held in the surgeon's left hand near its cutting end — being grasped 
in his full hand, the ulnar margin of his hand resting on the patient's limb 
to steady the instrument. The instrument should cut away from important 
structures, and preferably toward the surgeon. After each stroke of the 
mallet, the osteotome should be shifted, traveling back and forth in the line 
of section, that it may not bind in any one place. In section of thick bones, 
if the instrument bind, it is withdrawn and a thinner (not narrower) one is 
introduced — and subsequently a still thinner, if necessary. Progress through 
the bone is determined by the skilled sense of touch. The section should be 
evenly made, as to depth, completely across the width of bone, traveling 
back and forth, no two blows being made in one site. Never remove the 
instrument from the groove in the bone when once the section has been 
commenced (unless a larger instrument catches in the section and has to 
be replaced by a thinner one), for it is often hard to regain the groove. The 
last portion of bone on the far side of the section, when important structures 
are just beyond, need not be cut with the osteotome, but may be bent or 
broken subsequently by manipulation of the limb. 

Division of Bone with Saw. — A special osteotomy saw, generally of 
the Adams type, is used. The operation is very similar to that just described, 
except in the substitution of the saw for the osteotome. The skin incision 
is placed as in the above operation, but is made with a tenotome instead 
of an ordinary knife — usually cutting in the line of the muscle-fibers and in 
the axis of the limb. When the bone is reached, the blade of the tenotome 
is turned so as to cross the bone transversely and is made to cut a path for 
the saw across the bone — the non-cutting part of the handle of the tenotome 
doing no harm to the soft parts between the bone and wound of entrance. 
When the way for the saw has been prepared, the tenotome is left in situ 
as a guide. Upon this the blade of the saw is introduced down to the bone 
and its cutting part pushed on across the portion of bone to be divided (Fig. 
1 68, A). The bone is to be sawed with short strokes, guarding against 
thrusting the point of the saw into the soft parts, especially at the beginning 
and ending of the section. The section may be nearly made with the saw 
and completed by manual bending or breaking. 

After-treatment. — Following osteotomy, the limb, or part, is in a con- 
dition of compound fracture made under the most favorable circumstances. 
Some form of splint, or a plaster-dressing, must immobilize the limb and 
keep the ends of the bones in apposition. The wound is closed by suture 
— no drainage being used in clean cases. 

Comment. — (i) In division by an osteotome, the osteotome itself is 
sometimes used to cut its way through the soft parts, instead of knife. (2) 
When the bone-section is nearly complete, bending is especially applicable 



LINEAR OSTEOTOMY BY THE OPEN METHOD. 



213 



in young tender bones. (3) The section of the bone should generally be 
completed by instrument, and not by breaking, as a splinter of bone may 
do damage to adjacent parts. 



LINEAR OSTEOTOMY BY THE OPEN METHOD. 

Steps of Operation Preparatory to Division of Bone. — The site of 
the bone-section is exposed by an incision so placed as to reach the bone 
most readily and safely, seeking an intermuscular plane where possible. 
Having passed through skin, fascia — and through or between muscles — ■ 
the soft parts are opened up and retracted to either side — and the region 
of bone fully exposed to view. Where it is possible to do so, and where 
it is not contraindicated, the periosteum is incised in the long axis of the 
bone, freed from its circumference, and retracted with the soft parts. The 
bone-section may then be made with an osteotome or with a saw: — ■ 

Division of Bone with Osteotome. — The osteotome is introduced at 
once upon the bone, in the direction the section is to be made — after which it 
is manipulated as in the 
subcutaneous method — 
much greater control 
of the instrument being 
possible. 

Division of Bone 
with Saw. — -The saw- 
is similarly introduced 
at once upon the bone, 
in the direction the sec- 
tion is to be made. 
The section is then 
made by short strokes, 
while the parts are well 
retracted and the entire 
operation exposed to 
view. 

After - treatment. 
— U n 1 e s s contraindi- 
cated, the periosteum 
should be sutured with 
gut — the sutures at the 
same time passing 
through the muscles and 
quilting them together. 
The wound is then 

closed in the usual way — and a retentive apparatus applied, as described 
in the last operation. 

Comparison. — In subcutaneous osteotomy the use of the osteotome is 
safer, less damaging, and the section is cleaner than by the saw. In open 
osteotomy the saw is preferable, especially the chain or Gigli saw. In the 
open method, while a larger wound of entrance is made, the bone-section 
is more accuratelv made and less damage is done to the neighboring tissues. 




Fig. 169, 



-Cuneiform Osteotomy: — Chisel is shown removing 
wedge-shaped piece of bone from bent tibia. 



214 OPERATIONS UPON THE BONES. 



CUNEIFORM OSTEOTOMY. 

Description. — A wedge-shaped piece of bone is removed, the size of 
which is determined by the needs of the case — the general rule being that 
the sides of the wedge should be at right angles to the axis of the bone just 
above and below the section — ordinarily, however, a smaller wedge suffices. 
The wedge usually extends entirely through the bone, its base being upon 
one surface and the apex upon the opposite — but it may extend only two- 
thirds or three-fourths of the way through, the balance being bent or broken. 
The operation is nearly always done by the open method. 

Operation. — Having exsanguinated the limb by elevation, followed by 
the application of a rubber tourniquet (which is much more frequently used 
than in the linear form of osteotomy) the limb is placed upon a sand-bag. 
The incision is placed over the site of the base of the wedge to be removed 
and is considerably longer than the base of the wedge — and is so planned 
as to enable the bone to be reached through the most direct and safest route, 
and to enable the muscles to be separated rather than cut. The skin and 
fascia are first incised — the muscles separated in their intermuscular cleavage 
line and retracted — and the periosteum incised in the axis of the bone, down 
to the bone, and retracted with, and adherent to, the soft parts. This clearing 
of the bone subperiosteally is accomplished with a curved periosteal elevator, 
the clearing being done more extensively at the site corresponding with the 
base of the wedge. The chisel is the best instrument with which to perform 
cuneiform osteotomy — though a chain or Gigli saw may sometimes be used 
advantageously, and even an ordinarv saw may be conveniently used in 
some cases of angular ankylosis (Fig. 169). The chisel is held like an osteo- 
tome, for the sake of steadiness. The beveled edge of the chisel is directed 
toward the wedge of bone to be removed. If the wedge be of considerable 
size, it cannot be removed with accuracy in one piece — a small wedge, narrow 
at its base, must be first removed — and then slices may be chiseled from the 
sides of this until a cuneiform space representing a wedge of the requisite 
size is removed. Having removed the wedge of bone, the ends of the bone 
are put into position — the periosteum is sutured with gut — the wound closed 
— and the limb put up in an immovable splint. 

Comment. — In this, as in the other forms of osteotomy, additional 
means may be used for holding the divided ends of the bone in place, besides 
the special form of splint — such as wiring, pegging, suturing, and other 
devices mentioned under operations for ununited fractures. 



THE OPERATIVE TREATMENT OF FRACTURES IN GENERAL. 1 

Operations for ununited fractures resolve themselves, as far as the forms 
of the bones are concerned, into three classes — those for fractures of the long 
bones — of the short bones — and of the mixed bones. The general principles 
involved are the same in all classes. Fractures of some special bones require 
special treatment. 

1 Much of what follows upon this subject is taken from a paper read by the author upon 
"The Operative Treatment of Fractures in General,'' before the surgeons of the Chicago, 
Hamilton, and Dayton Railway, at Dayton, Ohio; and before the New York Post-Graduate 
Clinical Society, and is here reproduced or modified by their courtesy. 



RESECTION FOR FRACTURED BONES. 215 

The principles involved: — the placing of freshened ends of bones in good 
position, without too great tension, and without intervening soft parts — and 
the maintaining of these ends strictly in position by competent immobilizing 
splint. 

Following is a brief summary of the technic employed in the majority of 
cases; — exposure of ends of bones as nearly subperiosteally as possible — 
resection of the ends as nearly transversely as the nature of the fracture will 
permit — if the ends of the bones can be easily approximated and easily retained 
in position, place them in apposition, suture the periosteum, approximate 
the muscles by buried sutures, close the wound, and apply an immobilizing 
splint. If the ends are not likely to be easily kept in approximation (especiallv 
as the result of an oblique section), one of the methods of holding them in 
apposition (to be described below) may be resorted to — in addition to placing 
the ends in contact and applying a retentive form of apparatus. 

In operating, some form of tourniquet is usually applied. The site of 
operation is to be shaved. The position of patient, surgeon, and assistant 
will be determined by the special operation. 

The instruments used are those employed for Osteotomy (page 210). 

The subject of the Operative Treatment of Fractures may be considered 
under several headings: — (I) Operative Methods of Approximating and 
Fixing Ends of Fractured Bones — (2) Operative Treatment of Simple Frac- 
tures — (3) Bone Grafting, or Implantation — (4) Operative Treatment of 
Delayed Union, Non-union and Mal-union — (5) Operative Treatment of 
Compound, Comminuted, and Complicated Fractures — (6) Operative Treat- 
ment of Fractures Involving Joints, and of Fracture-dislocations — and (7) 
Operative Treatment of Separated Epiphyses. 

The results to be aimed at in fracture-treatment are — union without 
deformity — without impairment of function of limb — and with as limited 
loss of time and usefulness as possible. 

To summarize the status of fracture-treatment, it may be said that the 
present treatment of fractures is in a transitional stage — and is now in the act 
of passing from the routine, hard-and-fast, prolonged splinting, which was 
in common use until a very short time ago — to the more rational methods 
of the present time, which include the use of early passive movements and 
massage in conjunction with removable splints, and the practice of open 
incision in appropriate cases. 

Various methods are in use for bringing the ends of fractured bones into 
apposition and holding them in place until bony union has occurred. The 
best form of internal fixation for the special case cannot be known in advance 
of the actual exposure of the parts involved. The technic of exposing the 
ends of the bones, however, does not materially differ, no matter what form 
of internal fixation be employed — and this technic, therefore, will be first 
briefly described — and then will be enumerated the most generally used 
methods resorted to for holding the broken bones together. 



OPERATION FOR RECENT OR UNUNITED FRACTURE BY RESECTION 

OF ENDS OF BONES, WITH RETENTION OF COAPTATED ENDS BY 

IMMOBILIZING SPLINTS. 

Description. — The ends of the bones are exposed and excised, and the 
freshened ends are then brought into contact and held in apposition by a 
splint or a plaster cast. 



2l6 



OPERATIONS UPON THE BONES. 







Take, fur an example of the technic, the operation for the repair of a 
simple recent fracture by resection of the ends of the bones, with retention of 
the coaptated ends by immobilizing splints — where no form of mechanical 
fixation is used other than that secured by placing the ends of the sawn bones in 
proper relation and holding them in such relation by splints. (And what is 
here said of recent fractures applies also to ununited fractures.) In many cases 
of recent fracture the nature of the broken ends might be such as not to require 
their resection prior to the application of the special form of internal fixation. 

Operation. — Hav- 
ing exsanguinated the 
limb and applied a 
tourniquet, an inci- 
sion, sufficiently free 
to allow of protrusion 
of the ends of the 
bones, is made in the 
long axis of the limb, 
directly over the ends 
of the bones — and 
placed so as to give 
free access by the most 
direct and safest route 
to the involved site. 
The skin and fascia 
are divided — the mus- 
cles are separated in 
their intermuscular 
planes and retracted 
— or, if separation of 
the muscles in their 
planes be impossible, 
they are divided as nearly in the direction of their fibers as possible. Important 
vessels and nerves are carefully avoided, being retracted to one side. The wound 
is made fully large and the lateral retraction of the soft parts sufficient to make 
the necessary manipulations possible without adding to the traumatism. 
The ends of the bones are fully exposed and entirely freed of all tissue which 
may intervene between the fragments, whether normal or cicatricial. As 
the ends of the bones are approached, care is taken to avoid injuring the 
periosteum — which should be split longitudinally and freed circumferentially 
from the ends of the bones, without otherwise severing its connection, and 
should be raised without separation of overlying muscle, that is, as a musculo- 
periosteal covering. The end of each bone is dealt with in turn, and, after 
being thoroughly freed, is, where possible, protruded through the wound, 
the limb being bent at an angle for this purpose and the soft parts well retracted, 
the periosteum being carefully peeled back during this step. A minimum 
slice of bone is now removed from the end of each bone, simply enough to 
insure a fresh, raw surface upon each. If the bones have been protruded, 
this section is generally best made with a butcher's saw. If the ends have 
not been protruded through the wound, after they have been well freed, it is 
best to slip a chain or Gigli saw between the bone and the periosteum and thus 
make the section. The section may also be made, though generally less 
satisfactorily, with a chisel. The direction of the section will depend largely 
upon the nature of the ends of the bone; — if a rather transverse fracture, the 




C D 

-I. — Operations for Ununited Frac- 
tures by Simple Section: — A, B, Simple transverse fracture, 
followed by transverse section of bones; C, D, Irregularly trans- 
verse fracture, followed by section of bone parallel with fractures. 



SUTURING FOR FRACTURED BONES. 



217 



section is made transversely; — if a very oblique fracture, the section is made 
obliquely (Figs. 170-173, A, B, C, D; and Figs. 174-177, A, B, C, D). 
Whether the section be made transversely or obliquely, the section is so planned 
as to leave a limb in correct position, as to its axis and as to its rotation, and 
is so made as to secure 
two parallel surfaces for 
contact. An exception 
to this is where some 
special form of section is 
made, as when the bones 
are so sawed as to have 
an angularity of one fit 
into a depression of 
another, producing the 
mortising effect — the 

great principle being that 
the ends of the bones 
should be cut so as to fit 
each other. A transverse 
section of the bones is 
always preferable, unless 
involving too great a sac- 
rifice of length. The 
ends are now approx- 
imated in the position in 
which the bones will re- 
main, and are held in this 
position during the re- 
mainder of the operation and until the permanent splint be applied. The 
periosteum is sutured with gut. The muscles are brought together with buried 
gut sutures. The outer wound is closed in the usual way. The limb is then 
placed in a permanent splint, or in a plaster cast, with extreme care, so steady- 
ing the parts during the dressing that the ends of the bones remain undisturbed. 
Where the case is one of mal-union, either the ends of the mal-united bones 
are excised, or the badly united ends are sawn or chiseled apart, after which, 
in either case, the ends are treated as in cases of non-union. 

Comment. — (i) The operation is, practically, that of osteotomy by the 
open method. (2) In a recent case, the after-treatment is that of a compound 
fracture, with the limb put up in a position to relax the pull on the fractured 
ends. (3) In old cases where bands of fascia, or tendons, are apt to draw 
the ends out of place, these should be divided. (4) Where it seems likely 
that the ends of the bones will tend to displacement, especially in such cases 
as the femur, a process of mortising may be carried out in fashioning the 
ends of the bones for approximation. 





-II. — Operations for Ununited 
Fractures by Simple Section: — A, B, Wedge-shaped and 
C, D, rectangular fracture, followed by section of bone par- 
allel with fracture. 



OPERATION FOR RECENT OR UNUNITED FRACTURE BY SUTURING 
OF ENDS OF BONES, WITH OR WITHOUT RESECTION. 

Description. — Instead of simple approximation of the broken ends and 
their retention by splints applied to the outer surfaces of the limb, some form 
of mechanical device may be also used to hold together the ends of the bones 
themselves. In such cases, having exposed the site of fracture by, approx- 



2l8 OPERATIONS UPON THE BONES. 

imately, such steps as those just described, the broken ends of the bone are 
now to be brought into apposition and fixed by some special method selected 
by the surgeon — of which the following are the chief procedures in use — it 
being understood that these methods apply equally, whether the case be a 
recent fracture, an old fracture with pseudarthrosis, a non-union, a mal-union, 
a simple fracture, or a compound fracture — and whether the form of 
fixation be employed after the ends of the bone have been resected, or 
without resection. In the method about to be described, in addition to 
the retention of the coaptated ends of the bones by splints, the ends 
are previously drilled and held in contact by some form of suturing. In 
the case of new fractures, where the ends are left so shaped as likely to remain 
in position when sutured, resection of the ends of the bones need not be done 
— otherwise the ends should be resected. In all cases of old fracture the 
ends of the bones are always resected, so as to present freshened surfaces. As 




Fig. 178. — Method of Drilling Bone for Wiring: — A, Bone-holding forceps; B, hand-drill. 



the chief dependence is in the ultimate bony union between the fractured 
or resected ends, and as the chief function of the retaining substance is tem- 
porarily to hold the ends in position until union is sufficiently advanced to fix 
the ends of the bones firmly and permanently, it is unquestionably best to use 
the material which, while fulfilling that temporary office, will then disappear 
of its own accord and give no future trouble — and, therefore, kangaroo tendon, 
or heavy, 30-40-day chromic gut, is the ideal material for this purpose. Of 
the soft materials, silk and silkworm gut are also used. Of the non-absorbable 
metallic substances used, silver wire is the most frequently employed. The 
wire should be of different sizes for different bones. It should be of pure 
silver, or it will not stand as much strain on twisting. It should be cut into 
lengths and straightened. Each piece should be heated to a dull red heat in 
the flame just before using (in order to make it much more pliable and less apt 
to break) — then cooled and dropped into sterile solution ready for use. Some- 
times wire is used with the intention that it should only remain in temporarily 
and be removed when its usefulness is at an end — -but generally it is hoped 



SUTURING FOR FRACTURED BONES. 



219 



that it will remain in permanently — the ends of the wire, therefore, are treated 
according to the views entertained. The general method of applying the 
suture, no matter what the material, is the same. 

Operation. — The steps of the operation are the same, in all respects, as 
for resection with retention by splints — up to the exposure and clearing of 
the ends of the bones — after which the technic will differ, dependent upon 
whether the bones are resected or not; — (a) Suturing of the bones without 
resection: — The ends of the bones are grasped and steadied by some special 
foim of bone-holding forceps, while holes for the passage of wire are drilled 
— sufficient in number to furnish the desired strength and so planned in 
position as to retain the normal axis of the bone (Fig. 178). The holes may 
be drilled and the suture passed in several ways. Where the fracture is 
practically a transverse division of the bone, the drill-holes are usually made 
to pass through one wall of the upper and the corresponding wall of the lower 
fragment, the suture thus passing through but a small portion of the medulla 
of the bone (Figs. 179-181, A, B, C). In the case of an oblique fracture, 




Figs. 179-181. — Operations for Un- 
united Fractures by Section \nd Sutur- 
ing : — I. — In transverse fractures; — A, Single 
suture through both walls of each bone; B, 
Double suture through both walls of each 
bone; C, Sutures passed through single wall 
of each end. These forms may be used 
without section of bone. 



C 1 m 




Figs. 1S2-1S4. — Operations for Un- 
united Fractures by Section and Suturing: 
— II. — In oblique fractures; — A, Double sutures 
through both walls of each end, in axis of bone 
(not advisable); B, Same, crossing fracture at 
right angle (advisable); C, Loop of suture 
carried through drill-hole, and free ends brought 
around bone and through loop and twisted. 
These forms may be used without section of 
bone. 



the holes may be drilled and the suture passed in the same way — or the 
fragments may be held in position and the holes drilled through opposite 
walls and the intervening medullary substance (Figs. 182-184). In the 
case of wire, the ends, in either of the methods above mentioned, may then 
be twisted, cut short, and pressed into the periosteum and bone — or may 
be twisted long and brought out of the wound (Figs. 185-187 and 188-190). 
In both methods the periosteum is pierced by the suture, though elsewhere it is 
preserved as intact as possible upon the bones. In previously drilling the 
holes for the passage of the suture, the most useful instrument to have at hand, 



220 



OPERATIONS UPON THE BONES. 



next to one of the many forms of bone-drill, is a pair of stout bone-holding 
forceps with fenestrated blades — by which the bone is firmly held and through 
the fenestrated openings of which the drill is applied, thus steadying both the 
bone and the drill-point (Fig. 178). (b) Wiring of the bones after resection: — 
The resection of the ends of the bones is accomplished just as in the operation 
for ununited fracture by resection of the ends of the bones, with retention of 
the coaptated ends by immobilizing splints (page 215). The ends of the bones 
are then drawn back into their musculo-periosteal sheaths — and the ends are 
then sutured as in (a) above. Following the approximation of the ends 
of the bones, the periosteum is sutured with gut — the muscles are brought 
together with buried gut sutures — the outside wound closed as usual — and 




Figs. 185-187. — Operations for Un- 
united Fractures by Section and Wir- 
ing: — III. — By simple loop-ligatures: — A, 
By double loops around bone at right angle 
to axis of bone; B, Double loops at right 
angle to line of oblique fracture; C, Double 
loops, as in A, reinforced by lateral wire- 
loops. These forms may be adopted without 
section of bone. 




Figs. 188-190. — Operations for Ununited 
Fractures by Section and Wiring: — IV. — By 
frame-ligature; A, B, C, First, second, and third 
stages of the frame-ligature. 



an immobilizing splint applied. The wire is not expected to be removed 
when buried, — when left long, it is subsequently (after firm union) untwisted 
and drawn out, to accomplish which it is sometimes necessary to expose the 
parts by incision down to the bone. 

Comment. — The drill-holes should be a little larger than the silver wire 
used. The wire should be fairly heavy. The holes are drilled from 8 mm. 
to 1.3 cm. (I to \ inch) from the ends of the bones, penetrating obliquely 
if but one wall of the upper and one wall of the lower fragment be drilled — 
and penetrating at a right angle to the surface, if the drilling pass transversely 
through opposite walls. In drilling for oblique fracture, the suture should 
pass at a right angle to the line of fracture. 



METHODS OF FIXING ENDS OF FRACTURED BONES. 221 

OTHER OPERATIVE METHODS OF APPROXIMATING AND FIXING 
ENDS OF FRACTURED BONES. 

In the various forms of mechanically uniting ununited bones, about to be 
described, the preliminary steps of exposing and preparing the ends of the 
bones for coaptation, whether resection has been done or not, are the same 
as those given in the preceding operations. 

Union of Fractured Bone by Metallic Nails or Ivory Pegs. — While 
the ends of the bones are held in firm contact in the grip of strong, fenestrated, 
bone-holding forceps, plated nails are so driven as to bind both ends — or 
ivory pegs are inserted through previously drilled holes. The nails usually 
protrude through the skin and are subsequently withdrawn (in about two 
weeks) — whereas ivory pegs are generally cut flush with the bone and are 
left, in the hope that they will become incorporated with the osseous tissue 
(or they, too, may be left long and be withdrawn). If the fracture or section 
be transverse, the nails or pegs are put in obliquely, passing from without 
through the proximal wall of the upper fragment, through the medullary 





Fig. 



191. — Uniting Fractured or Re- 
sected Bone by Nailing. 



Fig. 192. — Uniting Fractured or Re- 
sected Bone by Pegging. 



substance, and into the wall of the lower fragment, from within outward. 
Two or more nails or pegs are generally inserted, passing in different direc- 
tions (Figs. 191 and 192). If the section, or fracture, be oblique, the nails 
are put in at a right angle to the surface of bone and pass transversely through. 
As little damage as possible is done to the periosteum. The muscles are 
brought together by buried gut sutures — the wound closed — and the limb 
immobilized. 



2 22 



OPERATIONS UPON THE BONES. 



Union of Fractured Bone by Metallic Screws. — The technic is here 
very similar to that in the lust proceeding, except that plated screws replace 
the nails. The holes for the screws which bind the two fragments are first 
drilled of a slightly smaller size than the diameter of the screws — which are 
driven home with a screw-driver until their heads are flush with the periosteum. 
It is necessary to have a large variety of screws on hand, especially as to 
length. They may remain permanently in situ — or may be cut down upon 
and unscrewed. 

Union of Fractured Bone by Metallic Plates and Screws. — Following 
the technic of Steinbach, silver plates of various sizes and shapes are used, 
secured in position by small galvanized steel screws — those, for example, for 
the tibia, their most useful field of application, are 6 mm. (\ inch) thick, 
g cm. (T>h inches) long, and 8 cm. (j| inches) wide, and with screw-holes 1.2 cm. 
(| inch) apart. Having retracted the soft parts without disturbing the 
periosteum, the screw-holes are first drilled a size slightly smaller than the 
screws, some into the upper fragment, some into the lower, and the drilling 
is continued until loss of substance shows that the medullary cavity has been 
entered, when the screws are driven firmly into place by means of a screw- 
driver. When bony union is solid, the plate is generally cut down upon and 




Figs. 193 and 194. — Uniting Fractured or Resected Bone by Screwing: — Screws may 
be used alone — or in metallic plates, as shown in diagram to left. 



the screws unscrewed, and all removed. The plate is sometimes left per- 
manently in situ (Figs. 193 and 194). 

Union of Fractured Bone with Metallic or Bone Ferrules. — Rings of 
thin metal, of some width, or of bone, are slipped over the ends of the broken 
bone — especiallv in the case of oblique fractures. The metallic ferrule is 
difficult to remove, should it become necessary, even if split on one side. The 
bone ferrule becomes absorbed. 



METHODS OF FIXING ENDS OF FRACTURED BONES. 



223 



Union of Ununited Fracture by Parkhill's Clamp. — The fragments 
of bone are here held together by means of a special form of clamp consisting 
of four long steel screw-pins and an interlocking mechanism. The ends of 
the bones are exposed and freed in the ordinary manner — and resected, if 
necessary. Two holes are drilled in the long axis of each fragment, in direct 
line with each other. Four long steel screw-pins are then screwed into these 
holes by means of a clock-key attachment — after which the "wings" of the 
instrument are adjusted. While the ends of the bones are held in accurate 
apposition and care taken that the proper axis of the bone is secured, the 
two fragments are clamped together in the special manner of the instrument. 
The muscles and other soft parts are then adjusted about the screws of the 
clamp, which projects without the wound. The dressing is then applied — 




Fig. 195. — Operation for Fractured 
or Resected Bone by Parkhill's Bone- 
clamp: — Surface view of clamp in position. 



Fig. 196. — Operation for Fractured 
or Resected Bone by Parkhill's Bone- 
clamp: — Side view of clamp in position. 



and the pins of the clamp not removed for from four to six weeks (Figs. 195 
and 196). 

Ligation of Bone. — One or more pieces of wire are passed around the 
fractured portion of bone, either at a right angle to the axis of the bone or 
at a right angle to the line of fracture. These are twisted, cut short, and 



224 



OPERATIONS UPON THE BONES. 



buried. The bone may be notched to aid in holding the wire in place. Longi- 
tudinal Loops may unite the circumferential wire bands (Figs. 185-187 ). 

Combined Ligature and Suture. — A hole is drilled through the frag- 
ments at a right angle to their line of fracture — a loop of wire is passed through, 
given a half-turn in the center, and the two ends passed around the sides of 
the bone and through the loop and twisted (Fig. 184, C). 

Frame Ligature of Bone.— Drill two holes through the fragments, 
in the long axis of the bone — pass the free ends of a wire loop through the 
holes — pass the loop over the free ends and draw tight — then bring the -free 
ends around to the holes through which the looped end originally passed and 
carry them under the wires emerging from those holes and twist them together 
in the long axis of the bone (Figs. 188-190). 

Intramedullary Pegging. — Pegs of ivory, or of fresh or decalcified 
bone, are lightly driven into the medullary canal of one bone, and the ends 
of the fractured bone so displaced, temporarily, as to enable the medullary 
cavity of the opposite fragment to be slipped over the opposite end of the 
peg (Figs. 197 and 198). Where there has been a loss of substance of bone 





Figs. 197 and 198. — Operation for 
Fractured or Resected Bone by Intra- 
medullary Pegging: — A, Peg is seen in 
medullary cavity of lower bone, and about to 
be introduced into that of upper; B, Peri- 
osteum is being sutured along margins of bone. 



Fig. 199. — Operation jor Fractured 
or Resected Bone by Intramedullary 
Pegging : — Where part of one bone has been 
excised and periosteum is being sutured 
around peg. 



and the periosteum corresponding to the absent bone is preserved, this has 

been sutured over the bone peg with success, especially in the young (Fig. 199). 

Summary. — In summing up the subject of the mechanical fastening of 

the ends of broken bones, it will be seen that the uniting substance may be 



OPERATIVE TREATMENT OF SIMPLE FRACTURES. 225 

buried in tissues with the hope that it will remain quiescent — or, if suitable 
for absorption, that it will be absorbed — while, on the other hand, substances 
are sometimes put in temporarily, with the purpose of removing them when 
they have accomplished their object and the parts have become solidly united. 
The best method can only be determined when the parts are exposed — and the 
best method of internal fixation is that method which immobilizes most 
efficiently. The guide for the selection of the special form of this internal 
fixation will depend, in part, upon the special bone involved and the nature 
of the fracture — and, in part, upon the views and habits of the surgeon as to 
retentive appliances. The judgment of the writer would be distinctly in 
favor of kangaroo tendon, or 30-40-day chromic gut — as being an absorbable 
substance, and as being a method of wider range of applicability to the various 
fractures of the body than any other. The strength of either of these sub- 
stances is sufficient to retain the ends of fractured bones in contact the necessary 
length of time, if properly handled— at the end of which time absorption usually 
renders any further dealing with the wound unnecessary. If the limb be 
carefully held by an assistant assigned to that duty alone, so that the tendon or 
gut is not put upon the stretch before the limb is secured in its splint, these 
substances would probably never. stretch to an extent harmful to the interests 
of the fracture, as claimed — and which has been an objection raised by some. 



OPERATIVE TREATMENT OF SIMPLE FRACTURES. 

Of the various applications of operative treatment to fractures, the question 
of the operative treatment of simple fractures is probably the most interesting 
at the present time, for not only is the field for the application of operative 
interference greater in simple fractures than in any other form of fracture, 
or in any result of fracture, but the practice itself is comparatively new, and 
the opinion of the profession at large has not yet been definitely formulated 
as to the full scope of the technic and the variety of cases to which it should 
be applied. 

As matters stand at present, the number of surgeons who are operating 
in cases of simple fracture seems to be steadily increasing. 

Compound or open fractures have always received some form of operative 
treatment, if only to the extent of cleaning the site and putting the parts into 
favorable position for repair, and comminuted and complicated fractures 
have frequently received such treatment, so that the application of a somewhat 
more radical operative treatment than heretofore to these classes of cases is 
not so distinctly new — but the treatment of simple or closed fractures is a 
new field brought up in surgery during comparatively recent years. 

The argument that the operative treatment of simple fractures converts 
every simple fracture into a compound fracture does not carry with it the same 
gravity as formerly, for in the vast majority of cases such a procedure carried 
out with thorough asepsis is accompanied by comparatively little risk. It may 
be said that the way to the operative treatment of simple fractures was paved 
by the operations of osteotomy, by the subcutaneous and open methods, for 
all such operations made compound fractures of the cases, and results in such 
instances nearly invariably come to a satisfactory conclusion without untoward 
complications. 

*The special objects accomplished by the open operation in fractures, in 
those cases where it is indicated, are the following: — ends of bones may be 
accurately approximated by fingers and instruments while in view and acces- 
l 5 ' 



226 OPERATIONS UPON THE BONES. 

sible in the field; — these ends may be permanently fixed in normal position by 
whatever means are chosen; — some fractures which cannot be reduced at all 
by the ordinary methods can be reduced by open operation; — many fractures 
which are reducible by the ordinary methods only with difficulty and uncer- 
tainty can be reduced with ease and accuracy; — the ends of many fractured 
bones not capable of being retained in position by postural treatment are 
easily retained by internal fixation; — ankylosis is often avoided in fractures 
near to and involving joints; — partially separated and detached periosteum 
may be replaced, and sutured if necessary; — a correct diagnosis is possible; — 
all tissues intervening between the ends of the bones can be removed and 
placed in normal positions; — clots of blood may be gotten rid of; — injury done 
to the neighboring structures may be repaired; especially torn nerves may be 
sutured; compressed nerves freed of their pressure; divided vessels ligated; 
lacerated muscles repaired; and spiculae of detached bone removed; — inflamed 
processes are often reduced; — the amount of callus is generally lessened; — 
shortening is prevented; — deformity is less frequent; — the period of disability 
is considered by some surgeons to be lessened by one-third; — and a gain in 
the range of function is often secured. The open method of treatment is 
especially applicable to many compound fractures, comminuted and com- 
plicated fractures, old fractures with deformity, cases of non-union, and 
fracture-dislocations. These results, it must be admitted, are weighty con- 
siderations, and it must also be admitted that some of these objects cannot be 
accomplished at all by the ordinary methods of treatment, and that many of 
those which are accomplished by the usual methods are accomplished more 
by accident than by intelligent design, for the ordinary method of treating 
most fractures is, both figuratively and literally, by working very much in 
the dark, as to both sight and touch. 

Briefly, the object of operative treatment of fractures is, in the language 
of Van Werden, "to bring into apposition, and hold in contact by direct 
temporary mechanical measures, the different anatomical constituents of the 
wound until the process of repair throughout is complete." 

Operative treatment is fully warranted, therefore, and should be unhes- 
itatingly undertaken where the complete reduction of the fracture and the 
retention of the ends of the bone in good apposition by simpler means are 
impossible; where complications otherwise irremediable exist; and is further 
warranted whenever it is considered that a distinct gain in time to the patient 
and increase in function of the part can be expected from open operation. 

The compound fracture is here made through a region aseptically ready 
for it and but slightly apt to resent it. In operating upon fractures immediately 
after the accident, the soft parts offer no great opposition to extension and 
replacement, but after a few days have elapsed, physiological shrinkage may 
offer so much opposition to extension and replacement as to be relieved only 
by flexing the contiguous joints or by division of tendons and fascia. 

Having determined upon operation, the general manner of exposing 
the parts is similar in technic to that already described under Operative 
Methods of Approximating and Fixing Ends of Fractured Bones, and will 
not be given in further detail here. 

After having exposed the ends, the interlockable nature of the fragments 
may be such as to make any other form of fixation other than simply causing 
the ends to interlock, unnecessary. Some form of mechanical fixation, 
however, is generally done; the writer would prefer, as indicated above, kan- 
garoo tendon or chromic gut in the great majority of cases. 

The operative treatment of simple fractures should be carried out imme- 



BONE-GRAFTING OR BONE-IMPLANTATION. 227 

diately after injury, and if this cannot be done, some surgeons wait until a 
week has elapsed. 

Where irregularly fractured ends can be interlocked in their normal relation- 
ship before being sutured, their holding together is more firm than if they had 
been sawed, and the full length of the limb is maintained. 

It has only been since the introduction of the open method of treating 
simple fractures that the difficulties in their reduction, up to that time con- 
cealed by unbroken skin, have been so clearly demonstrated. Of these several 
difficulties the greatest is caused by the shortening of all the soft parts in the 
region near the break, which, in turn, is caused by inflammatory action, 
hemorrhage into the tissues, and by contraction of the tissues themselves — 
for after the fracture there is no resistance to the contraction of the soft parts, 
as compared to their normal stretched condition. The bones are thus pulled 
together, and, where the nature of the fracture makes it possible, causes an 
overriding of the ends. This condition of contraction is prevented when 
internal fixation of the fragments has been satisfactorily accomplished. 

BONE-GRAFTING OR BONE-IMPLANTATION. 

Bone-grafting consists of the transplantation of living bone, or periosteum, 
from the same or different individual, or from an animal, into the defect to be 
repaired. 

There is another group of substances which cannot be strictly called 
bone-grafts, but which are rather to be regarded — either as "scaffoldings," 
or "trellis-works," along which bone-material may grow in the process of 
repair — or as irritants which serve to provoke this osteoplastic process. Such 
are: dead bone, variously prepared and rendered aseptic — bone-plates — bone- 
ferrules — calcined bone — decalcified bone — and even fresh bone with its 
periosteum and endosteum scraped off — and bone-chips. 

It has not been absolutely decided whether the living graft ever remains 
as such and grows — or whether it does not always disappear after exciting 
new bone-formation. It is held by some that the implanted bone lives — by 
others, and this is more probable, that it does not live as normal bone. Valan 
holds that the center of the graft dies, but that the periphery becomes fused 
with the living bone and lives. In still other cases it neither grows itself nor 
excites new bone-formation — but, in such cases, and where the operation and 
its subsequent course are aseptic, it may cause the formation of firm fibrous 
tissue which is almost as serviceable as bone. 

The return to its site of the button of bone temporarily removed by tre- 
phining is one form of bone-implantation, where the trephining may be 
regarded as a deliberate fracture or solution of bony continuity made by the 
surgeon for some specific object. An osteoplastic amputation, such, for 
example, as those about the lower extremity, is an illustration of bone-trans- 
plantation designedly made in the course of an operation. Of the artificially 
prepared substitutes for bone, calcined bone, either in the form of coarse 
granular powder or in the form of plates, would seem to be an approximate 
physiological substitute for bone, supplying, as it does, the lime salts. It is 
easily prepared — easily sterilized — readily fills the cavities — and is so porous 
that it is gradually replaced by bone which grows over it and through its 
interstices as over an arbor. The calcined bone-plates are made from the 
cancellated bone of the scapula of calves. It is held by Valan that calcined 
bone is better to use than decalcified bone — because the resulting bone-tissue 
is stronger. 



228 OPERATIONS UPON THE BONES. 

The chief indication for hone-grafting, or bone-implantation, is to fill 
in the interval left by lost bone in such conditions as compound or comminuted 
fractures, where the bone is very much fragmented and the pieces are nearly 
or entirely detached, or seem unlikely to live; in mal-union, necessitating opera- 
tion, with loss of bone; to restore the continuity of long bones where all or a 
considerable portion of the shaft is lost; and in deformities, to replace destroyed 
bone. 

There are several varieties of bone-grafts: (I) Detached portions of 
human bone (from the same or another individual), living at the time of 
detachment from the donor, and implantation into defect of recipient. (2) 
Detached portions of animal bone, living at the time of detachment from donor 
and implantation into defect of recipient. (3) Portions of human bone 
adherent by periosteum, soft parts, and vascular supply to an adjacent part 
of the donor's body (as in fractures and deformities about the face). (4) 
Portions of animal bone adherent by periosteum, soft parts, and vascular supply 
tn an adjacent part of the donor's body. 

There are now a sufficient number of authentic cases of extensive successful 
bone-grafting from the lower animals to man to warrant the expectation that 
the technic of this operation will be rapidly elaborated, and the field of its 
usefulness greatly expanded. 

The manner of exposing the site to be grafted is the same as that described 
under the operations for exposing the ends of fractured bones for the purpose 
of applying internal fixation; or a preexisting wound, or other circumstances, 
may determine the method of exposure. Where the bony defect is of a 
limited nature, this defect may often be repaired from the adjacent bone of the 
individual himself — by clipping off portions of the bone and periosteum and 
wedging them in between the ends of the bone by means of an osteotome or 
chisel. If small pieces of bone can be chipped off from the ends of the broken 
bone and packed into a tube of periosteum connecting these ends, there is 
an especially favorable outlook for bone-formation. If a periosteal tube be 
absent, the soft parts may be brought around the grafts and held in place by 
catgut sutures. Some surgeons prefer human and some animal grafts. 
The latter must, of course, be much more generally available. The animal 
graft may be implanted as a solid piece of the required length, or a piece of 
the proper length may be split longitudinally into several small pieces and 
these inserted into the gap, with their periosteum adherent. Where a graft 
fails to take in the gap between the ends of one of the bones in a double-bone 
limb, a portion of the second bone should, in appropriate cases, be excised to 
correspond with the opposite gap, thus making both bones of the same length. 
This, however, should only be done as a last resort. 

OPERATIONS FOR DELAYED UNION, NON-UNION, AND MAL-UNION 

OF FRACTURES. 

Delayed Union. — Fractures which have resisted the ordinary attempt to 
bring about union by the usual form of procedure — as carried out by those 
who are in the habit of submitting the great majority of fractures to splinting 
and. its accessories — are usually, and generally rightly, subjected to a second 
treatment by the same means, with especial attention to constitutional indica 
tions, and possibly more active out-of-door life. Where, on the other hand, de- 
layed unions are treated by those who more frequently adopt the open operation 
in even simple fractures, they will probably be subjected to operative treatment 
upon their first failure to unite — in which cases they will come, as far as 



OPERATIONS FOR DELAYED UNION OF FRACTURES. 229 

operative technic is concerned, within the following category, which they 
resemble in all but their duration. 

Non-union. — The two most usual methods of treating non-union, after 
having exposed the parts, are, first, to resect the ends, bring the bones into 
apposition, and hold them in this position by plaster or other splinting, or, 
secondly, after having resected the ends, to bring and hold the bones together 
by some form of internal fixation, if possible, preferably by kangaroo-tendon 
or chromic gut, or by silver wire; or, where the resulting gap is too great in 
the involved bone of a double-bone limb, by bone-grafting. The technic of 
exposure is the same as that given under the operative method of approxi- 
mating and fixing the ends of fractured bones. In addition to the technic 
there given, the callus and all inter-fragmentary tissues are to be removed 
by knife, scissors, and bone gouge. Where a condition of pseudarthrosis 
exists, the structures entering into the formation of the false joint are all 
thoroughly cleared away. The ends of the bone are then sawed off squarely 
or shaped so as to hold more firmly when brought into apposition, orotherwi>e 
resected, as indicated by the special form of fracture, or, in some cases, may be 
simply scraped with bone gouge. The ends are then brought together by 
the form of internal fixation selected, or the intervening gap filled with a bone- 
graft, as just indicated. The periosteum, if preserved, is sutured with catgut, 
the muscles separated in the approach are brought together by buried gut 
sutures, if need be, the wound is closed without drainage, and the limb put up 
in its splint. 

Mal-union. — -Occurs most usually in the upper third of the femur 
or middle of the humerus. The deformity may be simply a shortening of the 
limb from overlapping of the fragments, the limb remaining in its normal 
axis; or an angularity may exist, which is more serious when near a joint. 
The treatment for mal-union should invariably be by open osteotomy; where 
a simple transverse, linear osteotomy, or cuneiform osteotomy, as indicated, 
should be done; or, if marked, the deformed site of fracture may be excised. 
Where it is possible to do so, the bone section should be made as subperios- 
teally as the condition of the original torn periosteum permits, that is, a 
longitudinal incision should be made through the periosteum over the bone, 
during the latter steps of the approach to the bone; beginning well over the 
sound periosteum of the upper bone, and extending well over that of the lower 
bone, and the two lips of periosteum peeled back from the bone, at the site 
where the section is to be made, until the entire circumference of the bone is 
exposed, and then the bone, bared of periosteum, is to be divided by linear or 
cuneiform osteotomy. In this way the periosteum is left intact to materially 
aid in the regenerative process of callus formation. If the bone of a single- 
bone limb, or appropriate bones of head or trunk, have been thus divided, the 
ends should be drilled and brought together with kangaroo tendon, or chromic 
gut, which, when the periosteum has been first temporarily removed from the 
bone at the site, is inserted through the bone, but not through the periosteum, 
so that the periosteum is allowed to fall back in place, and overlie the suture 
knots. If, on the other hand, the bone is one of the bones in a double-bone 
limb, if a tangible piece with parallel ends be removed, the ends left after 
the incision cannot, of course, be approximated and sutured (owing to the 
fact that the length of the limb or part is maintained by the other bone), and, 
in these cases, the site has either to be put up with the ends of the involved 
bone apart, or, which is probably better, the empty casing of periosteum can 
be filled with either a single bone-graft or bone-grafts, and its lips sutured 
over such graft or grafts. Even the empty casing of the periosteum, although 



230 OPERATIONS UPON THE BONES. 

partly collapsed by the pressure of soft parts, would probably produce bone 
which would fill in the gap between the ends. Excision of a corresponding 
length of the opposite bone in the double-bone limbs is sometimes done, but 
is not so desirable. In any of these cases the limb is subsequently treated 
as one with a compound fracture made under favorable circumstances. 
Under no circumstances should the deformity of a badly united fracture be 
corrected by osteoclasis, for all methods of bone-breaking are crude, uncertain, 
dangerous to neighboring parts, and are distinctly unsurgical — nor is the 
subcutaneous division by saw, or osteotome, of the bone or bones involved 
in the mal-union warrantable. 

OPERATIVE TREATMENT OF COMPOUND, COMMINUTED, AND COM- 
PLICATED FRACTURES. 

Compound Fractures. — The progressive advance in the treatment of 
compound fractures is one of the most marked illustrations of the evolution of 
conservative surgery. At one period a very large percentage of compound 
fractures came to amputation — and in many hospitals it was the accepted rule 
to amputate all limbs above the site of a compound fracture involving a large 
joint. Then followed a period when conservatism was shown by saving the 
limb at the expense of shortening it, by making an excision at the site of com- 
pound fracture, including a joint, if necessary. At the present time still 
further conservatism is accomplished in many cases by neither amputation nor 
excision, but by freely exposing the parts by operation, correcting the damage 
done to neighboring soft structures, thoroughly disinfecting the part with 
antiseptic irrigation, followed by aseptic douching, treating the ends of the 
bone as indicated by the conditions found, carrying out some method of internal 
fixation of broken ends, and putting the limb in an open or fenestrated splint. 
Owing to the uncertainty of asepsis, drainage should generally be instituted 
at first. It should be maintained as long as the necessity for it exists, but can 
frequently be dispensed with in two or three days. The technic applies almost 
as forcibly to compound fractures with the smallest puncture, as to those with 
larger external wounds. The temptation may be very great to disinfect exter- 
nally, and to try to disinfect internally, an insignificant-looking puncture of a 
compound fracture and hermetically seal it with collodion, but subsequent 
septic developments will often cause regret. When the parts are exposed, the 
extent and nature of the damage may indicate the advisability of excision. 

Comminuted Fractures. — Comminution in a fracture may not be recog- 
nized by ordinary manipulation, and may only be demonstrated by .v-raying. 
Even when present, especially where simple and not extensive, it may not par- 
ticularly complicate the fracture. In such cases ordinary, non-operative treat- 
ment of the fracture may be carried out. But where the comminution is more 
extensive or more complicated, or even where, when simple, comminution 
prevents the exact approximation and retention of the bone-ends in position, 
the involved site should be unhesitatingly cut down upon and dealt with as the 
needs of the special case require. The fragments can often be tied together 
or sutured to one end of the main bone with chromic gut. Large fragments 
whose periosteum has been entirely torn off are not so likely to unite, but small 
chips of bone will. A bond of union by periosteum with the main bone, or 
with a larger fragment, is very useful in bringing about bony connection. 
Pieces of bone will frequently live even when taken out of the wound, disin- 
fected and replaced, and often even if they have been reversed in position and 
order. Entirely detached bone can, therefore, be removed temporarily, disin- 



OPERATIVE TREATMENT OF FRACTURE DISLOCATIONS. 23 1 

fected in 2\ per cent, carbolic solution, or 1-1000 bichloride; rinsed in warm, 
sterile, normal salt solution, in which they should stay until needed, and 
returned to their normal position, where, if possible, they should be secured to 
a neighboring bone by gut suture. If much periosteum has been lost, the bone 
should be covered with soft connective tissue and muscles (which may be held 
about the bone with buried gut sutures). In cases of extensive comminution, 
excision of the bone-ends may be called for, followed by internal fixation of the 
ends -r by bone-grafting. 

Complicated Fractures. — One of the strongest arguments in favor of the 
more general treatment of fractures by operative measures followed by internal 
fixation is that open incision, which gives free access to the fracture, also gives 
full opportunity to rectify, or treat as indicated, the special complication of the 
case, which complication may be more important than the fracture itself. So 
that, apart from the general operative technic of exposing, approximating, and 
fixing the bone fragments, already described, the special treatment of the case 
becomes the treatment of the predominating complications, whatever they may 
be, whether involving arteries, veins, nerves, viscera, or other soft structures, 
and their line of treatment will be determined by the structure involved and 
the nature of its injury. 



OPERATIVE TREATMENT OF FRACTURES INVOLVING JOINTS AND 
OF FRACTURE DISLOCATIONS. 

Fractures Involving Joints. — The difficulties in fractures involving 
joints treated by non-operative methods are, first, the almost impossibility of 
getting the fragments into normal position; secondly, the keeping of them in 
place; and, thirdly, the prevention of deformity and limited movement. While 
the certainty of accomplishing these desirable ends does not by any means 
necessarily follow operative treatment, yet the chance of accomplishing them 
by open incision is much greater than without. 

When, therefore, examination under anesthesia and with the x-ray (which 
should always be used in these cases, and are very serviceable in all cases) show 
that the broken bones will not stay in very accurate apposition when once 
reduced, the fractured ends should be cut down upon and united by internal 
fixation (especially here by some absorbable suture) ; the joint cleared of effused 
blood and inflammatory products; the wound temporarily drained, and the 
limb put up in a splint. It must be remembered that union has to be unusually 
accurate in these cases, as the slightest irregularity upon the articular surface 
of a bone is apt to lead to impaired joint movement. By this course of treat- 
ment passive movement and massage are also made possible earlier, with the 
consequent likelihood of the prevention of both extra- and intra-articular 
adhesions, and, therefore, an increased range of functioning. 

Much of what was said under extra-articular compound fractures also 
applies to intra-articular compound fractures. Formerly, many compound 
fractures involving joints cost individuals the amputation of the limb above 
or at the site of fracture. Then, as a great advance upon this destructive sur- 
gery, immediate excision of the joint was generally done, in order to get a mov- 
able joint and avoid sepsis. Now, one asepticizes the involved regions, and is 
thoroughly conservative, and though he may have to excise later, generally a 
shorter excision (less loss of bone) can usually be accomplished secondarily 
than primarily. 

It is to be remembered that while the skin wound of a compound fracture 



232 OPERATIONS UPON THE BONES. 

may extend into the joint, the fracture itself may not do so, which somewhat 
simplifies matters. 

Dislocations Complicating Fractures. — When a fracture is not imme- 
diately near a dislocated joint, and where operative treatment is not indicated, 
reduce the dislocation first (putting up the broken limb in temporary splints, 
so as to be able to manipulate it somewhat more freely), then reduce the fracture 
and so splint the limb, incasing it as a whole, that passive movements of the 
joint may be begun early. 

When the fracture is near the joint, the distal bone was formerly put up in 
line with the proximal one, and when the fracture was well, the dislocation was 
reduced, but now the more rational technic is to expose the parts by operation, 
and first to reduce the dislocation and suture up the capsule, and then approxi- 
mate the ends of the broken bone by internal fixation. The limb is then put 
up in a splint and massage begun early. 



OPERATIVE TREATMENT OF SEPARATED EPIPHYSES.. 

In attempting to reduce fractures of the epiphyses, wherever it is found 
that an exact alignment of the epiphysis with the shaft can not be obtained, or 
where obtained, it can not be maintained, some form of operation is indicated. 

It has been found that it is best, in operating upon separated epiphyses, to 
avoid the use of any mechanical means which penetrates the epiphyses and 
remains any length of time as an irritant (as, for example, a nail), for while an 
uninjured though detached epiphysis may retain its integrity for some weeks 
and then grow to the main bone when replaced, yet if, on the other hand, con- 
stantly irritated by this foreign body, it may either suppurate or undergo hyper- 
trophic overgrowth. 

The treatment of epiphyseal separation differs in many instances materially 
from the treatment of a fracture in the same locality, and especially is an accu- 
rate knowledge of the contiguous anatomy necessary in dealing with such cases. 

If operative treatment were done as a more systematic procedure in the 
treatment of such injuries, there would not be so many deformed limbs and 
joints. 

When deformity occurs from arrest of growth in one of the parallel bones of 
the double-bone limbs, conjugal chondrectomy (that is, excision of the con- 
jugal cartilage of the corresponding normal bone) should be done, if the age 
of the normal bone is not too great, namely, beyond its period of active growth. 

Epiphyseal separation occurs in a vastly larger number of cases among males 
than among females, and the separation of the epiphyses of the upper extremity 
is more frequent than of the lower. 

Separation of epiphyses occurs in the following order of frequency: Upper 
epiphysis of humerus, lower of radius, lower of femur, lower of tibia. 

^c-Raying is of little or no assistance in the diagnosis of epiphyseal separation, 
as the epiphyses are transparent to these rays. The greatest diagnostic aid is 
gotten by manipulation under anesthesia. 

Operation, where the epiphysis cannot be certainly and satisfactorily manip- 
ulated into place, consists of exposure, followed by suturing the epiphyses to 
the shaft with tendon or gut, and, where the epiphysis is entirely or partially 
intra-capsular, of closure of the capsule. 



STIMSON'S OPERATION FOR FRACTURED PATELLA. 233 




Fig. 200.— Operation for Fractured Patella by Stimson's Method of Mediate Suture : 
— A, Heavy silk suture (of mattress variety) passing through greater thickness of quadriceps extensor 
tendon, above, and ligamentum patellae, below; B, Chromic gut suture of torn capsule and fibro- 
periosteum. 

OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 

BY SUTURING OF SOFT PARTS. 

stimson's METHOD. 

Description. — The margins of bone, after being cleared, and, if necessary, 
freshened, are held in position by a heavy silk suture-loop passed trans- 
versely through the quadriceps extensor tendon above, and the ligamentum 
patella. 1 below. 

Position. — Patient supine; limb fully extended. Surgeon on side of 
operation. Assistant opposite. 

Landmarks. — Contour of patella. 

Incision. — Median, in long axis of limb, with its center over center of 
patella and extending considerably above and below the patella but not 
passing into muscular tissue. 

Operation. — The incision extends through skin, fascia, prepatellar bursa, 
expansion of quadriceps extensor tendon, and periosteum directly to the 
patella bone. The soft parts are well retracted, so as to expose the entire 
extent of the transverse fracture (which is possible because of the length 
of the incision) (Fig. 200). The joint is irrigated to remove the clots. If 
the fracture be recent, no removal of fibrous tissue or bone is necessary. If 
old, each fragment is carefully seized with bone-holding forceps and steadied 



234 OPERATIONS UPON THE BONES. 

in such a position as to render it accessible to the saw, and a thin slice of 
bone is then removed. A heavy silk ligature, threaded upon a curved needle, 
is now carried transversely through the ligamentum patella? near its apex, 
passing through about two-thirds of its width and thickness — then trans- 
versely through the quadriceps extensor tendon, near the upper border of 
the patella, also passing through about two-thirds of its width and thickness. 
While the fragments are held in close contact this ligature is tightly tied. 
The torn capsule on either side of the patella and the fibro-periosteum are 
sutured with chromic gut. The fibrous tissues overlying the patella, and 
divided in the median incision, may then be sutured with buried gut suture. 
The skin wound is closed. No drainage is used. The limb is put up in 
full extension. 

Comment. — In some old cases the quadriceps extensor tendon has con- 
tracted to such an extent that it is necessary to lengthen the common quad- 
riceps extensor (see operation for muscle-lengthening, page 246). 



OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 

BY WIRING OR SUTURING OF BONE AND SOFT PARTS. 

Description. — The ends of the bones, after being cleared, and, if neces- 
sary, freshened, are drilled and wired together, the wire being buried and 
left — or they may be sutured with an absorbable material. The joint may 
be exposed by a median vertical, transverse, or by Cheyne's oval incision — 
the last being here described. 

Position — Landmarks. — As in the above operation. 

Incision. — Oval, outlining a flap with upward convexity, which is raised 
from over the patella and temporarily turned downward. The incision 
begins 2.5 cm. (1 inch) to one side of the patella, on a level a little below 
the fracture — extends vertically upward and then curves across the front of 
the thigh about 2.5 cm. (1 inch) above the upper border of the patella, and 
descends on the opposite side to a point corresponding with its commence- 
ment. This flap-incision gives a full field and places the scar above the 
patella. 

Operation. — The fractured ends of the bones are exposed, the joint 
irrigated, and the fragments slightly everted and examined. All interposed 
periosteum, fibrous and other tissue are removed. In recent cases no removal 
of bone is ordinarily indicated. In old cases a thin slice of bone is removed 
from each fragment. Each fragment is now grasped in turn by means of 
stout bone-forceps, injuring the bone as little as possible while firmly steadying 
it (Fig. 201). One, two, or three wire sutures, as seem indicated, are now 
introduced in the following manner; — Two holes are drilled directly opposite 
each other in a vertical line, in the upper and lower fragments, a short incision 
being made for the drill through the fibrous covering of the patella, within 
8 mm. to 1.3 cm. (^ to \ inch) of the fractured edges — the margins of the 
incision through the fibrous tissue being drawn aside and the drill (hand or 
motor) directed obliquely, so as to come out at the fractured margin after 
having passed through about two-thirds of the thickness of the bone. All 
the drill-holes are first made, and are made from without inward. Care is 
taken that each pair of holes is drilled immediately opposite and that their 
points of emergence on the fractured surfaces are on the same level. The 
wires are now passed, are grasped with strong forceps, and, while an assistant 
firmly approximates the margins of the fragments, these wires are tightly 



OPERATION FOR FRACTURED PATELLA BY WIRING. 



235 



twisted for three or four turns, cut off about 6 mm. (J inch) long, bent upon 
the bone, and slightly buried by one or two blows of the mallet. The peri- 
osteum which has been drawn out from between the fragments of bones 
is stitched together with chromic gut to the opposite lip of the torn periosteum. 




Fig. 201.— Operation for Fractured Patella by Wiring:— a. Lower fragment of patella 
steadied with hone-holding forceps ; B, Drill in act of making holes for passage of silver wire, one 
piece of which is seen in position ; C, Chromic gut suture of torn capsule and fibro-periosteum. 



The rent in the capsule generally found on each side of the fractured patella is 
similarly sutured with gut. The fibrous covering of the patella, incised in 
raising the oval flap, is sutured with buried gut. The wound is closed through- 
out — no drainage being used. The limb is put up in full extension. 

Comment. — Chromic gut, kangaroo tendon, and silk are also used in 
the same manner as wire. 



236 



OPERATIONS UPON THE BONES. 



OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 

BY AN ENCIRCLING SUTURE OF THE SOFT PARTS. 

Description. — Having exposed the fracture, an encircling suture of kanga- 
roo-tendon, chromic gut, or silver wire is carried through the soft parts border- 
ing upon the patella, including the quadriceps extensor tendon, the ligamentum 
patellae, and the capsule — which is then tightened and tied or twisted, while 
the fragments are held in close apposition. 

Position;— Landmarks.— As in the preceding operations. 




Fig. 202. — Encircling Suture used in Fracture of Patella: — The suture passes 
through the quadriceps extensor tendon above, through the ligamentum patellas below, and 
through the capsule and lateral ligaments at the sides. The transverse rent in the capsule is 
then sutured separately. 



Incision. — The patella may be exposed by either of the incisions just 
described — or a flap with downward convexity may be raised. In the latter 
instance a flap with downward convexity is outlined, which will be the reverse 
of the one in the preceding operation. It begins 2.5 cm. (1 inch) to one side 
of the patella, on a level a little above the fracture — extends vertically down- 
ward and then curves across the front of the leg about 2.5 cm. (1 inch) below 
the lower border of the patella, and ascends on the opposite side to a point cor- 
responding with its commencement. This flap-incision gives a full field and 
places the scar below the patella. 



OPERATION FOR RECENT FRACTURE OF OLECRANON. 



237 



Operation. — As to the exposure of the fractured parts, the steps of the oper- 
ation are in every respect similar to those in the operation described at page 233, 
the manner in which the patella is surrounded with the ligature alone differing. 
By means of a Reverdin needle heavy kangaroo-tendon is carried in and out 
through the soft parts bordering upon the patella, including the extensor quadri- 
ceps tendon, the ligamentum patellae, and the lateral aspects of the capsular 
ligament, in the manner shown in Fig. 202. Chromic gut or silver wire may 
be used. In the case of using the last, it is drawn into position by means of a 
silk carrier. After the suture has been placed, the fragments of the patella 
are drawn into very close apposition by pointed retractors pulled in opposite 
directions — during which close contact of the margins the suture is drawn 
tight and tied, or, in the case of wire, twisted. The rent in the capsule and 
lateral ligaments is then closed, from one extreme lateral aspect to the opposite 
and across the front of the patella, as in all operations upon the patella. The 
flap is now brought down and sutured along its margin — without drainage. 

Comment. — The circular suture may be carried continuously through the 
substance of the quadriceps extensor tendon and the ligamentum patellae. 




Fig. 203.— Operation for Fractured Olecranon by Wiring : — A, Drilling holes for pas- 
sage of silver wire, one suture being seen in position, and one being drawn through ; B, Chromic gut 
suturing of torn capsule and nbro-periosteuni. 



238 OPERATIONS UPON THE BONES. 

OPERATION FOR RECENT OR UNUNITED FRACTURE OF OLECRANON 

BY WIRING OR SUTURING OF BONE AND SOFT PARTS. 

Description. — The olecranon is quite frequently fractured at its junction 
with the shaft of the ulna — and is repaired by wiring or suturing in the same 
general manner as in the case of fracture of the patella. 

Position. — Patient supine; forearm drawn across chest, by an assistant 
on the opposite side, presenting to the surgeon the semiflexed elbow, while 
exposing the fragments; and fully extended by the side while suturing. Surgeon 
stands opposite the elbow. 

Landmarks. — Contour of olecranon; shaft of ulna; condyles of humerus. 

Incision. — The site of fracture may be exposed — (1) By an oval incision; — 
beginning to one side of lateral border of olecranon, just below the fracture 
— passes upward in axis of limb for about 2.5 cm. (1 inch) above the olecra- 
non — thence curves across arm and descends to a corresponding point on the 
opposite side — thus furnishing a free exposure of the fracture and providing 
a scar which falls out of the way of pressure. (2) By a median longitudinal 






Fig. 204. — Encircling Suture used in Fracture of Olecranon: — The upper limb 
of the suture is shown passing through the olecranon; and the lower limb through the shaft of 
the ulna. 

incision; — beginning and ending considerably above and below the line of 
fracture, but not involving the muscles above or below — and having its center 
over the fracture. The length of this incision allows of sufficient lateral 
retraction to well expose the parts (though less perfectly than the incision 
just described). 

Operation. — The incision passes through skin, fascia, bursa, fibrous 
expansion of the triceps tendon, and periosteum directly onto the bone 
(Fig. 203). The manner of exposing the fractured ends, irrigating the 
joint, removing a slice of bone from each fragment in old cases, drilling the 
fragments, passing and tightening the wire, suturing the torn periosteum and 
fascia, and closure of wound are similar, in all practical essentials, to the 
corresponding steps in the operations just described upon the patella (page 
234). The limb is put up in full extension. 

Comment. — (1) Chromic gut, kangaroo tendon, and silk may be used 



SEQUESTROTOMY. 



2 39 



instead of wire. (2) In some old cases, where much retraction of the triceps 
has occurred, that muscle should be lengthened, as described under muscle- 
lengthening (page 246). (3) Instead of passing the sutures in the way indi- 
cated above, an encircling suture may be carried in such a manner as to pass 
through the shaft of the ulna below, and through the triceps tendon above and 
be tied on one side, as shown in Fig. 204. The capsule and lateral ligaments 
are closed by sutures. 

SEQUESTROTOMY. 

Description. — An operation for the removal or excision of a sequestrum 
(dead bone) en masse. The operation might be more properly termed 
sequestrectomy. The site of the sequestrum is generally determined by the 
presence of one or more sinuses, together with the history of the case. 

Position and Preparation. — Patient is so placed as to expose the in- 




Fig. 205.— Cross-section of Leg, Showing a Sequestrum-cavity. 

volved site most conveniently. A constrictor is usually applied, where 
possible, to control hemorrhage. 

Landmarks. — Generally the existence of one or more sinuses; the known 
anatomy of the part. 

Incision. — Generally placed in the long axis of the limb, or in such a 
position as to fall in with the intermuscular cleavage line and so as to lead 
to the site by the safest route — with its center over the sinus, or extending 
between the two chief sinuses (Fig. 205). 

Operation. — The incision passes down to and through the periosteum. 
The soft parts, including periosteum, are then retracted laterally, fully exposing 
the bone in the neighborhood of the sinus, or between two or more sinuses. 
It may be at once possible to grasp the sequestrum with strong forceps 
introduced through the sinus-opening and draw it out — or the sinus-opening 
may be sufficiently enlarged for this purpose by rongeur forceps. If neither 
of these can be clone, the sinus may be enlarged with the curved chisel — 
or the bone between two sinuses may be chiseled away — or the bone may 
be chiseled away in the long axis of the sequestrum, even where but one 
opening exists — or a trephine-opening (one or more) may be made instead 
of using the chisel. Following the removal of the sequestrum, the cavity 
of the bone should be well scraped. The periosteum and muscles are then 
united by buried gut sutures, and the skin closed with sutures of silkworm - 
gut or silk — drainage being established to the bottom of the bone cavity 
in the most favorable position. If the limb be weakened by the operation, 
it should be put up in a splint. 



240 OPERATIONS UPON THE BONES. 

Comment. — Bone-chips may be used in the cavity — or the entire thick- 
ness of the soft parts, including periosteum, may be inverted into the bottom 
of the bone cavity from each side and held in place by a nail or peg (Fig. 
206). Or the cavity may be packed throughout with gauze. 




Fig.206— Sequestrotomy:— Neuber's Operation. The antero-internal aspect of the tibia is 
removed— sequestrum cavity scraped— the integumentary tissues nailed to its floor— and relaxation 
sutures placed. 

OSTEOPLASTY. 

Description. — Transplantation of bone — in the form of bone-chips or 
decalcified bone-fragments — which are placed in the desired site and among 
which organization of the blood-clot takes place. The transplantation of 
a larger section of bone, entirely detached, has not yet been commonly done — 
though the success of reinserting the trephine-buttons suggests the practi- 
cability of such a course. This principle will be further mentioned under 
osteoplastic amputations. 

Operation. — The site of operation having been rendered bloodless by 
a proximal constrictor, and having provided the bone-chips in advance 
(which come specially prepared by decalcification), the locality is exposed. 
If the chips are to be used within a bone cavity, such as a scraped medullary 
cavity, it is seen that this is thoroughly aseptic before their introduction. 
If they are to be used within a periosteal cavity (as after the partial resection 
of a bone), this periosteal cavity should be kept as nearly like the special 
form of the original bone as possible. In the case of the bone cavity, the 
bone-chips are dropped into the cavity and the soft parts sutured as just 
described in the above operation. In the case of a periosteal cavity, sutures 
of gut are made to approximate the periosteal margins over the included bone- 
chips — and the muscles over the periosteum — and finally the skin, in the usual 
manner. The tourniquet is then removed and the blood allowed to flow 
into the part and fill the interstices between the bone-chips. The part is 
usually put up in an immobilizing splint. 

Comment. — If the neighboring parts do not cover the site in which the 
bone-chips have been deposited, they may be covered by sterilized rubber 
tissue. Other applications of osteoplasty are mentioned under Bone-grafting 
(page 227). 

EXCISION. 

Excision of the bones is described under the general head of Excisions 
and Osteoplastic Resection of Bones and Joints (pages 463 to 531). 



CHAPTER VI. 

OPERATIONS UPON THE JOINTS. 

EXPLORATORY PUNCTURE OF JOINTS. 

Description. — The exploration of the fluid contents of a joint by means 
of the needle of a suction-syringe — for the purpose of ascertaining the nature 
of those contents — or for the evacuation of the fluid found. 

Indications. — Collection of pus, or other fluid, within a joint. 

Preparation — Position. — As for arthrotomy. 

Special Instruments. — Exploratory or aspirating syringe. 

Operation. — The same preliminaries having been observed as in ar- 
throtomy, the needle of the exploratory syringe is thrust, by the safest and 
shortest route, into the joint — the cylinder withdrawn and the contents 
aspirated. Following the withdrawal of the needle, the punctured wound 
is hermetically closed with sterilized collodion. 

ARTHROTOMY. 

Description. — A simple incision into a joint. 

Indications. — Exploration; removal of foreign body; evacuation of pus, 
or other fluid; irrigation; drainage. 

Preparation. — As for a major operation of the same joint. 

Position. — Determined by the special operation — and such as to render 
the site of incision prominent and convenient. 

Special Instruments. — Scalpel; dissecting forceps; artery-clamp forceps; 
retractors; tourniquet (sometimes). 

Operation. — The patient having been placed in a position to render 
the joint most accessible — and the overlying tissues in the best position with 
reference to the joint — an incision, of the simplest form and shortest extent 
compatible with the object in view, is made over that aspect of the joint 
which will lead into the interior of the joint-structures by the route which is 
shortest and safest, both in regard to the joint-structures and the tissues 
intervening between skin and joint. Having opened up the joint, the sub- 
sequent steps will depend upon the special object of the operation; — (a) 
Where exploration is the object; its interior is examined by some form of 
probe or sound, or, preferably, by the gloved finger-tip; — (b) Where the 
removal of a foreign body is sought; suitable forceps are introduced, with 
which it is grasped and withdrawn; — (c) Where drainage is indicated; a 
tube, or other drain, is inserted through the incision, with or without a counter- 
opening. In the first two cases, the wound is entirely closed. In all cases 
the joint is immobilized. 

ARTHROPLASTY. 

Description. — The formation of a movable joint, by the interposition 
between the loosened ends of the bones of some of the neighboring soft tissues 
or of some foreign material. 

Indications. — Ankylosis of the joints. 
16 241 



242 OPERATIONS UPON THE JOINTS. 

Preparation; — Position; — Incision. — Determined by the special oper- 
ation. 

Operation. — The site of the former normal joint is exposed in the usual 
manner. At the original joint-line the ankylosed bones are divided by means 
of a chisel or saw. All bone interfering with joint-movement is cut away. 
Synovial membrane and capsule are excised and any other structures apt to 
prevent movement of the new joint. Muscular and tendinous attachments 
are preserved. Shortened muscles are lengthened. All cicatricial tissue 
is removed. The preparation for the interposition of the neighboring soft 
parts must be thorough. A musculo-aponeurotic flap, covered by fat, and 
large enough to cover the ends of the divided bones, is raised from the neighbor- 
hood of the special joint and turned in between the sawn ends of the bones, 
and is sutured to the margin of the capsule which has been left in situ. Where 
the aponeurosis is insufficient, a muscle-flap, with as much adherent fat as 
possible, is used. The part is immobolized for a week or more — after which 
passive motion is begun (with anesthesia if necessary), followed my massage — 
irrespective of the suffering caused, as the production of a joint will depend 
upon the transformation of the interposed tissue to a bursa. 

Comment. — Animal membrane, such as a piece of bladder, has been used. 
Foreign substances have also been employed, such as silver, tin, rubber, cellu- 
loid, silver foil, and the like, in the form of plates — but the interposition of 
the neighboring soft parts, especially fat (which, under pressure, readily 
develops connective tissue and forms a bursa), produces the best results. 



ARTHRODESIS. 

Description. — The production of an artificial ankylosis in a joint by the 
removal of a part or all of the articular cartilage. 

Indications. — Sometimes resorted to in order to produce a rigid joint in 
certain muscular paralyses and flail-like joints. 

Preparation; — Position; — Incision. — Dependent upon the individual 
joint. 

Operation. — The special joint is exposed by a convenient incision. The 
articular cartilage entering into the formation of the joint is removed by means 
of a knife or chisel, in a thin layer, from the surfaces of the bones forming the 
joint. The denuded bones are then placed in apposition, and either held 
there by subsequent plaster dressing or splints, or by means of nailing or sutur- 
ing the parts together. The site is thus immobilized until ankylosis has 
occurred. 

Comment. — In some situations, the ankle-joint, for instance, the operation 
may be reinforced by the transplantation of tendons. 



ERASION OR ARTHRECTOMY. 

Description. — Etymologically, erasion signifies the scraping or curetting 
of a joint — and arthrectomy, the cutting out of a joint. Practically, both 
expressions are used synonymously — and are taken to signify the exposure 
of a joint with the removal of the diseased tissue alone. While arthrectomv 
signifies, literally, the cutting out of a joint, it is- not here used as the word ex- 
cision commonly signifies. In excision, the articular ends of the bones are 
invariably removed — in erasion or arthrectomy, while a certain amount of 



ERASION OR ARTHRECTOMV. 243 

bone may be incidentally removed (and always as much as is diseased is 
removed) in the gouging, only the articular cartilages and synovial membrane 
are supposed to be scraped or curetted. When bone is removed at all, the 
least possible is removed, and that is generally done with a gouge — and the 
whole operation conducted with as little injury as possible to the neighboring 
structures. In extreme cases all the articular cartilage is gouged away, all 
the synovial membrane is dissected out, and some of the bone is removed. 
An erasion or arthrectomy is, therefore, commonly understood as the applica- 
tion of scraping to the interior of a joint — the laying open of a joint and the 
removal of as many and as much of the tissues forming the joint as are dis- 
eased — synovial membrane, capsular ligaments, cartilage, and bone — the 
removal generally being accomplished by some form of gouge for cartilage 
and bone, and scissors and knife for soft parts. An arthrectomy, finally, 
may be regarded as a procedure the same in general purpose, though less 




Fig. 207.— Erasion of the Knee-joint: — A, Removal oi cartilage of condyle of lemur wilh 
raspatory ; B, Removal of cartilage of tibia with curette. The joint is exposed by a transversely 
curved incision and the patella turned backward. 

severe in degree, as an excision — and is distinctly a conservative measure espe- 
cially applicable to early cases. An arthrectomy is a part of every excision. 
Arthrectomy has its greatest application in joints of simple structure and easy 
approach — the knee being its most frequent site of application. A movable 
joint is always to be sought after erasion, even in the case of the knee 
(although in the latter case some surgeons prefer to secure ankylosis in 
preference to a probable weak joint). Arthrectomy is always preferable tc 
excision in children, owing to its non-interference with the growth of bone. 

Indications. — Disease of the articular structures, especially tubercular. 

Preparation — Position. — As for excisions (page 397). 

Special Instruments. — Besides those used for excisions, the following 
are specially required; — Gouges, curettes; spoons — of many sizes and shapes, 
dull and sharp. Flushing-gouges. 

Operation. — No form of constrictor is ordinarily used — though may be 
used, as in excisions. The incision is generally the same as that for the 
excision of the corresponding joint. Having exposed the interior of the joint, 
the following structures are closely examined, and, if necessary, removed 
— the guide being that all diseased tissue should be removed; — (a) Synovial 



244 OPERATIONS UPON THE JOINTS. 

membrane; where but slightly involved, is curetted, — where extensively, it is 
grasped with toothed forceps and dissected out, in as continuous a layer as 
possible, with scissors or scalpel. Every recess is sought and, if diseased, 
thoroughly curetted or removed, (b) Bursa* communicating with joint; are 
subjected to the same treatment as the synovial membrane — opened up 
and followed to their furthest extent, (c) Ligamentous tissue; to be scraped 
and cut away, (d) Articular cartilage; all involved or suspicious areas are 
gouged out with a sharp spoon, (e) Articular ends of bones; if actually 
diseased, or suspicious, to be removed with gouge, (f) Extra-synovial and 
extra-articular tissues; to be dissected out and removed, if involved. Finally, 
where much debris results, it is well to use a flushing-gouge and clean out 
the area of operation. Drainage is usually not necessary — but may be 
temporarily used where thought best. The capsular ligament, if not dis- 
sected away in removing disease, is closed by buried gut sutures. Muscles 
separated in reaching the joint are similarly brought together with buried 
gut sutures. The limb is put up upon an immobilizing splint. The after- 
treatment is practically the same as after excisions — and a more satisfactorily 
functioning joint is to be expected. (Fig. 207.) 



OPERATION FOR DISLOCATED SEMILUNAR CARTILAGES. 

Description. — A dislocated semilunar cartilage of the knee may be exposed 
and sutured back into position — or may be removed in part or in its entirety. 

Indications. — Those cases in which postural and mechanical treatment 
have failed. 

Preparation; — Position; — Landmarks. — As in the operation of excision 
of the knee-joint (page 521). 

Incision. — A vertical incision may be made to either side of the patella, 
dependent upon the particular semilunar involved. Or the entire joint may 
be exposed by means of a transverse curved incision, as for excision (page 522). 

Operation. — A sufficiently free exposure of the joint is made to enable 
manipulation of the involved structure. If the cartilage be only slightly sepa- 
rated from its peripheral attachment, or be torn to a limited extent radially, 
it may be sutured into its normal position with catgut sutures and the joint 
closed. If this technic does not promise to suffice, a portion of the cartilage 
may be excised. If a greater degree of separation or damage be found, the 
entire cartilage may be excised. The joint is closed without drainage, unless 
hemorrhage into the joint indicate the need for temporary drainage. The 
joint is immobolized for six to eight weeks — the muscles being kept up by 
massage in the mean time. The functional result of the joint is usually satis- 
factory. 

EXCISION. 

Excision of the joints is described under the general head of Excisions and 
Osteoplastic Resections of Bones and Joints (pages 463 to 531). 



CHAPTER VII. 

OPERATIONS UPON THE MUSCLES. 



MYOTOMY. 

Description. — Division of muscle — generally done as a preliminary to 
muscle-lengthening, or in the exposure of underlying parts, or in deformities. 

Operation. — The muscle is fully exposed by an appropriate incision — 
or is exposed in the course of some 
operation. Having been isolated 
from neighboring structures, the 
muscle is cleanly divided with a 
scalpel, cutting transversely, or 
very slightly obliquely, to the di- 
rection of its fibers. A grooved 
director may first be passed beneath 
the muscle, but is rarely necessary. 
Myotomy should be done by the 
open method. Muscles are some- 
times divided subcutaneously (as 
the sternomastoid, for torticollis), 
but this is even less advisable 
(owing to their greater size and 
less accurately defined contour) 
than the subcutaneous division of 
tendons. 

MYORRHAPHY. 

Description. — -Suturing of 
muscle which has been either pur- 
posely and cleanly divided (as in 
an operation) — or accidentally and 
unevenly divided or ruptured (as 
from injun- or from excessive 
action). 

Operation. — (a) Where mus- 
cle has been deliberately cut in the 
course of an operation, to expose 
underlying parts (as in dividing 
the sternomastoid in removing the 
cervical glands); — The muscle is 
here cleanly and evenly divided, 

preferably in a transverse or very slightly oblique direction. At the 
time of suturing, the parts are put into a position to relax the muscle as 
much as possible. While the two opposing ends of the muscle are carefully 
held in easy contact, as many muscle-sutures are inserted and tied as the 

2 45 




Fig.208.— Myorrhaphy : — The divided biceps 
is here shown sutured in several ways ; A, Mat- 
tress suture; B, Lateral knotted suture; C, 
Peripheral suture ; D, Lateral through-and- 
through suture; E, Antero-posterior through-and- 
through suture. The last two are here shown as 
relaxation — or reinforcing — sutures. 



246 OPERATIONS UPON THE MUSCLES. 

size and form of the muscle require. Chromic gut or kangaroo tendon is 
used for suturing — and the sutures are all buried. One of several forms of 
stitch may be applied. As the muscle-sutures are practically the same as 
tendon-sutures, and applied in the same manner, they will only be briefly 
mentioned here and their fuller description given under tendons, (i) Inter- 
rupted mattress sutures (Fig. 208, A). This is probably the best form of 
muscle-suturing. (The manner of its insertion is given at page 252.) (2) 
Interrupted sutures passing transversely through the upper and lower ends 
uf the cut muscle (page 252). (3) Lateral knotted sutures (Fig. 208, B) 
(page 253). (4) Simple, peripheral longitudinal coaptation sutures (Fig. 208, 
C) (page 252). (5) Relaxation sutures for reinforcement; — In any of the 
above forms of primary or coaptation sutures, one or more relaxation sutures 
of heavy catgut may be applied, passing transversely through the entire thick- 
ness of the muscle considerably above and below the primary sutures, and tied 
tightly enough to take the chief tension — and thus free the primary sutures 
from strain (Fig. 208, D, E). (6) Binnie's form of suture is particularly 
good — it is a continuous suture, passing well into the substance of the muscle 
and reinforced at intervals by transverse passage of the needle, (b) Where 
the muscle has been accidentally and unevenly ruptured; — The ruptured 
muscle is exposed by the safest, most direct, and least damaging route — remem- 
bering that the ends of the muscles may have retracted far away from their 
normal position. If the ends of the muscle have been left very irregular, they 
are carefully trimmed, and are then sutured in one of the above manners. If 
they be torn almost transversely, they are approximated and sutured 
without trimming. If much muscle tissue have been lost, or be sacrificed in 
trimming, some process of lengthening may have to be resorted to before the 
ends can be made to meet without too great tension (see muscle-lengthening, 
below). In order that the skin-incision, used in reaching the part, may not 
lie over the muscle wound, bringing two cicatrices directly opposite, a curved 
incision may be used — or an oval flap of overlying parts may be raised. In 
completing the operation, the part should be so immobilized in the dressing 
as to relax the muscle as completely as possible. 

MUSCLE-LENGTHENING. 

Description. — In old cases in which muscle tissue has contracted con- 
siderably (as in long-standing cases of fractured patella or olecranon) — or 
in cases in which much muscle tissue has been lost in injury, or has been 
sacrificed in trimming muscles for suturing — it is impossible to approximate 
the separated ends without too great tension, unless the muscle be lengthened. 
Muscle-lengthening, therefore, is resorted to in two sets of cases, — those in 
which muscle must be lengthened to enable parts below, other than the 
muscle, to be approximated without too great tension (as in the case of the 
triceps or the common quadriceps extensor, in fractures of olecranon and 
patella), — and those in which lengthening is necessary after an old transverse 
rupture of a muscle in which the ends are separated too far to allow of ap- 
proximation without too great tension (as in transverse rupture of the biceps 
muscle). In either category of cases the operation is the same. 

Operation. — The patient having been placed so as to relax the part 
completely, the site of lengthening is exposed by a longitudinal incision of 
about 7.5 to 10 cm. (3 to 4 inches) in length, placed over the involved muscle. 
The incision should be sufficiently long to afford free access and manipulation 
and planned to reach the parts by the safest, most direct, and least damaging 
route. Retract the overlying soft parts and isolate the muscle. Divide the 



MUSCLE-LENGTHENING. 



247 



muscle in a zig-zag line running transversely, and about 7.5 to 10 cm. 
(3 to 4 inches) above the ruptured part. This is a series of bluntly rounded 
serrations or V's — the incision passing upward about 5 cm. (2 inches) and 
downward the same distance, until the width and entire thickness of the 
muscle is traversed (Fig. 209, A). The muscle on either side of the zig-zag 
incision is now drawn apart until the apices of the V's touch. If the teeth 
or serrations are 5 cm. (2 inches) in length, when the suturing is done, 
nearly 5 cm. (2 inches) in length 
will be gained. The adjacent late- 
ral margins of the t.vo muscle-ends 
are now sutured by the knotted 
sutures described above (Fig. 210, 
E, E) (page 253). A V from above 
is now sutured, by the same knotted 
suture, or other form of suture, to 





Fig. 20Q.— Muscle-lengthening:— I.— Fig. 210.— Muscle-lengthening:— II. 

A, By means of a series of U-shaped incisions; — Manner of suturing the muscle-sections 

B, by a single long V-shaped incision. A case shown in the last illustration: A, Needle carrv- 
of ruptured patella is here represented. (The ing one part of a lateral knotted suture through 
manner of uniting these sections is shown in one of the tongues of the split muscle; B, 
the following diagram.) Opposite part placed; C, Each half tied and 

the free ends being knotted; D, A completed 
lateral knotted suture; E, E, Lateral knotted 
sutures approximating the bases of the tongues 
and also serving as relaxation-sutures; F, 
Suture of the tongue-and-groove suture. 

the A below, so that their blunted tips are held in contact by the sutures 
passed through above and below their tips (unless some such form of 
suture be used, as shown in Fig. 208, A, B, C, D). Theoretically, the apex 
of a V above will correspond with the base of a V below, but, practically, 
the apices are so disposed in the suturing as to bring them in contact. Suffi- 
cient length having been gained, the lower operation, for which the lengthening 
was primarily done, is now performed (an ununited fracture of patella or 



24S OPERATIONS UPON THE MUSCLES. 

olecranon, or ruptured biceps) — and unless this site has been exposed in 
the original incision, a separate incision is made for that purpose. Both 
wounds are then closed and the limb placed in a splint that will cause full 
relaxation of the parts during healing. Lengthening may also be accom- 
plished by a long V-shaped incision, as in Fig. 209, B, which is then sutured 
as shown in Fig. 210, F. Some of the methods of tendon-lengthening 
described on pages 254 to 259 are also applicable to muscles. 



CHAPTER VIII. 

OPERATIONS UPON THE TENDONS AND 
TENDON-SHEATHS. 

TENOTOMY. 

Description. — Division of tendons. 

Varieties. — Open Tenotomy, where the tendon is freely exposed before 





Fig- 2 1 1.— Open Tenotomy : — Of the tendo Achillis. 



being cut. Subcutaneous Tenotomy, where the division is made beneath 
the skin, by the sense of touch. Complete Tenotomy, where the entire thick- 

249 



250 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

ness of the tendon is divided. Partial Tenotomy, where a part only of the 
thickness of the tendon is divided, the remaining fibers being stretched. 

Indications. — Shortening of tendons. To prevent action of muscles. 

Special Instruments. — For open tenotomy; — scalpel; artery-clamps; dis- 
secting forceps; retractors. For subcutaneous tenotomy; — tenotomes, straight, 
curved, sharp and blunt. 

Open Tenotomy. — The tendon is here divided in an open wound. The 
incision for its exposure is generally made parallel with and directly over 
the tendon. The overlying soft parts are retracted — the tendon is exposed 
and isolated — and its sheath, if any, is opened. The tendon is then grasped 
with forceps and divided with a scalpel. The ends retract in both directions. 




Fig. 2 1 2. —Subcutaneous Tenotomy : — Of the tendo Achillis. 

The wound is entirely closed and the limb dressed upon a splint, or the part 
immobilized (Fig. 211). 

Subcutaneous Tenotomy. — The tendon is here divided subcutaneously, 
through the smallest possible wound. Having put the tendon upon the 
stretch, to render prominent, an incision is made parallel with and just to 
one side of the tendon to be cut, and so placed as to do the least damage 
to other structures in the neighborhood. The incision is first made with a 
sharp tenotome, through skin and fascia down to the tendon — upon this as 
a guide the blunt tenotome is passed sidewise (the sharp one being withdrawn). 
The tenotome is then insinuated beneath the tendon, which it closely hugs 
throughout. Sometimes temporary relaxation of the tendon will aid the 
passage of the knife beneath it. The cutting-edge of the tenotome is then 
turned outward — the tendon put upon the stretch — the forefinger of the 



TENORRHAPHY. 



251 



left hand being placed over the site of section as a guard and guide — and the 
tendon cut by a short sawing movement, the last fibers being cut carefully 
as the tendon is felt to yield. The knife is finally withdrawn upon its side. 
The wound is sutured and the limb dressed upon a splint '(Fig. 212). 

Comment. — (1) In simple sections where the tendons are easily accessible 
and the neighboring parts are not important, subcutaneous tenotomy may 
be done. Where the opposite conditions exist, open tenotomy should always 
be practised. (2) In doing subcutaneous tenotomy, the tenotome is some- 
times inserted between skin and tendon and the section made inward upon 
the tendon — which is more dangerous than cutting from beneath the tendon 
outward. 

TENORRHAPHY. 

Description. — Suturing of tendon. In recent cases the ends of the 
tendons can ordinarily be approximated without great difficulty. In old cases 
if the ends cannot be approximated and sutured after freshening them by 




Figs.2 13-2 16.— Tenorrhaphy : — A, Single suture through entire thickness of tendon; E, Two 
sutures entirely through tendon, in opposite directions; C, Peripheral sutures; D, Woelfler's quilt 
sutures. 



trimming, some method of lengthening must be used — and if their union 
cannot be accomplished by lengthening, transplantation to adjacent tendons 
may be resorted to. 

Varieties. — Primary, when the tenorrhaphy is done near the time of 
injury. Secondary, when done after healing. 

Operation. — In recent cases an already existing wound may be present 
(except in such cases as subcutaneous rupture of a tendon) — and where a wound 
is present, this is simply enlarged and the tendon more fully exposed and the 
ends isolated. Where no wound exists at the time of the tenorrhaphy, the 
main tendon and its ends are exposed by an incision which reaches the site 
by the safest and simplest route. In primary tenorrhaphy the ends may 
require no trimming, especially in clean cuts, — or but slight trimming. In 
secondary tenorrhaphy, a transverse or oblique section of the tendon ends 
is always necessary, prior to suturing. In either case, the opposite ends of 



25 : 



OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 



the tendons are brought well into the wound and approximated. Chromic 
catgut and kangaroo tendon are the best materials for uniting the ends. 
Several methods of suturing are used — the chief of which will be here de- 
scribed: (a) Interrupted sutures passing transversely through upper and 
lower ends of divided tendon (Figs. 213 and 214, letters A, B) ; — A straight 
needle enters the proximal surface of the upper portion and passes transversely 
through its thickness, about 8 mm. or 1.3 cm. (from ^ to ^ inch) from the 
cut margin — emerges at same level upon distal surface — crosses the gap- 
enters the distal surface of the lower portion, from 8 mm. to 1.3 cm. ($ to \ 
inch) from the cut end — passes transversely through — emerges at same level 
on proximal surface. The two ends of the suture are drawn upon until the 
tendon ends are approximated, and are then tied. When the tendon-ends 
have been cut obliquely, the sutures are so passed as to cross the line of 
division at a right angle (Fig. 222, B). (b) Interrupted mattress sutures; — ■ 
A curved needle enters the proximal surface of the lower portion, about 8 
mm. (3 inch) from its end — passes axially through two-thirds of the thickness 




Figs. 217-220. 



-Tenorrhaphy: — A, Mattress sutures; B, Same, tied; C, Lateral; knotted 
sutures (a less usual form of tenorrhaphy); D, Same, tied. 



of the tendon — emerges on the cut margin — crosses the gap to the upper 
portion — enters the cut margin about two-thirds its thickness from the prox- 
imal surface — emerges about 8 mm. (J inch) above the end — passes over 
the outer surface of the upper portion of the tendon for from 8 mm. to 1.3 
cm. (3 to ^ inch) — again enters the upper portion on a level with the point 
at which it has just emerged from the upper portion — passes through about 
two-thirds its thickness — emerges on the cut margin — crosses the gap to the 
lower portion — enters its cut margin about two-thirds its thickness from 
the proximal surface — and emerges on the proximal surface on a level with 
the original entrance — when the two ends of the tendon are drawn upon 
until the cut surfaces come well into contact and are then tied (Figs. 217 and 
218, A and B; and Fig. 216, D). (c) Peripheral longitudinal coaptation 
sutures; — A curved needle enters the lateral surface of the upper portion, 
about 8 mm. or 1.3 cm. Q to \ inch) from the cut edge — passes longitudinally 
through the tendon and emerges on the cut margin about 6 to 8 mm. {\ to \ 



TENORRHAPHY 



253 



inch) from the lateral surface — crosses the gap — enters the cut margin of the 
lower portion, from 6 to 8 mm. (j to ^ inch) from the lateral surface — passes 
longitudinally through the muscle and emerges on the lateral surface, about 
8 mm. to 1.3 cm. (^ to ^ inch) from the cut margin. The upper and lower 
ends of the sutures are now tied, approximating the tendons. These sutures 
are repeated at intervals of about 8 mm. to 1.3 cm. (J to \ inch) around the 
entire circumference of the tendon (Fig. 215, C). (d) Lateral knotted sutures; 
— A curved needle enters the lateral surface of the upper portion about 8 
mm. to 1.3 cm. (£ to \ inch) from the cut margin — passes transversely through 
the tendon tissue for about 8 mm. to 1.3 cm. (£ to \ inch) in width, and 8 mm. 
(| inch) in depth — and emerges on the level of entrance. The two ends 
of the suture are now tied, care being taken to but slightly, if at all, pucker 
the tendon — and one end of the suture is then cut short The same kind of 
suture is applied immediately below, in the lower portion of the tendon, and 
one end of the suture similarly cut short. The two long ends of the sutures 
are then tied together, thus approximating the two ends of the tendon. As 






Figs. 221-223. — Tenorrhaphy: — A, Reinforcing or relaxation suture, applicable to any 
form of suturing (shown with first turn of knot); B, Suturing of obliquely divided ends; C, 
Reinforcing through-and-through suture by lateral suture through loops of first suture (a less 
usual form of suturing). 

many of these pairs of sutures are introduced as necessary (Figs. 210 and 
220, C and D). The extreme margins of the tendon-ends may be further 
sutured, between these sutures, by method "c." (e) Relaxation sutures; — 
In any of the above forms of primary or coaptation sutures, one or more 
relaxation sutures of heavy catgut may be applied, passing transversely 
through the entire thickness of the tendon considerably above and below the 
primary sutures — and tied tightly enough to take the chief tension, and thus 
free the primary sutures from strain (Fig. 221, A), (f) Combination of the 
interrupted mattress (method "b"), or lateral knotted sutures (method "d"), 
with relaxation sutures (method "e"). Of these various methods, either 
method "a" or "b" is probably most generally applicable — the former 
especially in smaller tendons and the latter in larger. Having united the 
tendon-ends, the wound is closed and the limb put up upon an immobilizing 
splint. 



254 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

Comment. — (i) While a constrictor is not generally necessary, its use is 
ordinarily advisable. (2) Some surgeons prefer to expose the parts by a 
curved incision, beginning and ending over the tendon, above and below 
the rupture, but not over the rupture — so that there may be no possibility 
of adhesion between the tendon cicatrix and the skin cicatrix. (3) The 
ends of the tendons often form adhesions to their sheaths, and must be freed 
before they can be brought together. (4) All tendon-sheaths opened to expose 
tendons must be repaired with catgut. (5) The upper end of the divided 
tendon retracts further, and is harder to find, than the lower. The upper 
end retracts more because of the more active shortening of the proximal end 
of the muscle. It may be found, in hard cases, by "milking" the tendon- 
sheath downward — or by incising over the tendon higher up and tracing 
downward — or by incising the sheath in the lower part of the wound and 
tracing upward. The upper end of the tendon may sometimes be brought 
into view by extending the fingers or toes, the fibro-serous vincula pulling 
down the adjacent tendons. The lower end is generally not hard to be 
found — when hard, incise over the sheath lower down and trace upward — 
or pass a probe into its sheath from below and protrude it upward. (6) 
If the two ends cannot be found, one end must be transplanted into a neigh- 
boring tendon of the same group or function (see transplantation and grafting 
of tendons, pages 261 to 265). (7) The limb is put up so as to relax the 
tendon and muscle fully, and held so in a splint during union. After union 
has occurred, passive and active movements are begun early and persisted 
in — in order to prevent adhesion of tendon to sheath, and to get full range 
of movement. (8) It will be seen by comparing the illustrations of Neuror- 
rhaphy (pages 160 to 162) that many of the methods used in uniting nerves 
are applicable to the union of tendons, and vice versa. 



TENDON-LENGTHENING. 

Description. — Tendon-lengthening, sometimes called tendoplasty, is ap- 
plied to the lengthening of shortened tendons, or to the union of severed 
tendons, by processes of plastic elongation. 

Varieties. — Tendon-lengthening may be required in two classes of cases; 
— (1) Where the tendon is intact but shortened; — (2) Where the tendon has 
been severed and the divided ends have retracted. As to the time of per- 
forming the operation, tendon-lengthening may be either primary (done near 
the time of injury), or secondary (when done after retraction and healing). 

Operation. — Much that has been said under Tenorrhaphy, as to the 
exposure of the tendon, is equally applicable here — (see Operation, page 251, 
and Comment, page 254). Having exposed the shortened tendon, or the 
retracted tendon-ends, in the wound, one of several methods of lengthening 
may be applied — the chief of which will be here described: — (a) Operations 
for lengthening shortened intact tendons: — (1) By long oblique division 
of tendon, with gliding of beveled ends; — The obliquity of the division will 
determine the amount of lengthening — the ends being slid past each other far 
enough to still leave sufficient substance for union — and then the ends are 
sutured by several transverse sutures of chromic gut or kangaroo tendon. 
An oblique incision of 5 cm. (2 inches) will furnish a lengthening of from 
2.5 to 4 cm. (1 to ij inches) (Fig. 225, B). (2) By central longitudinal 
splitting of tendon with transverse division of the split ends and their 
approximation, surface to surface; — Having split the shortened tendon 



TENDON-LENGTHENING. 



2 55 




Figs. 224— 227.— Tendon-lengthening : — A, Splitting tendon transversely and longitudinally and 
suturing ends laterally ; B, Splitting and suturing tendon obliquely ; C, Splitting tendon obliquely and 
longitudinally and suturing split portions end-to-end ; D, Splitting one end obliquely and longitudi- 
nally and suturing the split end laterally to opposite unsplit end. 




Figs. 228-231. — Less Usual Forms of Tendon-lengthening: — A, Splitting one end 
longitudinally and transversely, reinforcing where bent, and suturing split end into opposite 
unsplit end; B, Splitting both ends longitudinally and transversely, reinforcing where bent, and 
suturing split portions end to end; C, Same, with suturing of split portions laterally; D, Same 
as last, with different sutures (lateral knotted and ordinary). 



256 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 





Fig. 232. — Bayer's Method of Tendon-lengthening: — A, The lines of through-and-through 

division of one-half the width of the tendon are shown. 
Fig. 233. — B, The appearance of the tendon after traction and the gliding of the longitudinal 

fibers past each other. 

down its center, as far as necessary to furnish the needed length, the ends of the 
split portion are divided transversely, or slightly obliquely, in opposite direc- 





Fig. 234. — A less Common Form of Tendon-lengthening: — A, The preliminary rectangular 

incisions. 
Fig. 235. — B, The subsequent appearance of the tendon after traction upon its ends. 



tions. They are then glided past each other and fastened laterally near their 
ends by two or more sutures passing through their combined thickness (Fig. 



TENDON-LEXGTHENIXG. 



257 



224, A). (3) By central longitudinal splitting of tendon with transverse 
division of the split ends and their approximation, end to end; — Somewhat 
similar to the method just described, except that the extreme ends of the split 
portions are sutured end-to-end, rather than surface-to-surface (Fig. 226, C). 

(4) Bv zig-zag incisions; — Incisions, transverse to the length of the tendon, 
are made on opposite sides of the tendon, passing half-way across, and not 
placed directly opposite each other. As many as are deemed necessary are 
thus placed, and the tendon lengthened by traction (Figs. 241 and 242, A, B). 

(5) A tendon may be lengthened by Bayer's method of partial division, followed 
by gliding the uncut fibers; — one-half of the width of the tendon is divided 
from its lateral (right) margin transversely to its center — and the opposite 
half of the width is similarly divided from its lateral (left) margin transversely 
to its center, but at a distance of 2.5 cm. (1 inch) or more from the first trans- 




Figs. 236-239. — Less Common" Forms of Tendon-lengthening : — A, Double splitting 
of both ends, reinforcing where bent, and suturing split portions end-to-end; B, Bridging with 
gut, or reinforcing or relaxing with lateral knotted sutures; C, Bridging with twisted gut; D, 
Interpolation with another piece of tendon. 

verse division. By putting the tendon under tension, the margins of the trans- 
versely cut portions separate, and the fibers of the portions between the cuts 
may be made to glide past each other as far as desired. The parts which are 
about to glide entirely out of contact may be reinforced by a double suture. 
(Figs. 232 and 233.) (6) A tendon may be lengthened by being incised as 
shown in Fig. 234, A — followed by traction and the production of the effect 
shown in Fig. 235, B. (b) Operations for lengthening shortened severed 
tendons: — (I) By partially splitting one end, twisting the split half, and 
suturing it to itself and to the end of the opposite end. Calculating the required 
amount of tendon needed, the upper end of the tendon is partially split, twisted 
upon itself, and sutured to itself — and its free end sutured to the opposite lower 
end of the unsplit tendon (Fig. 227, D; and Fig. 228, A). (2) By partially 
.splitting both ends, twisting the split portions and suturing them to themselves 
17 



258 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

and to the end of the opposite end. This is the application to both ends of 
the principle applied in "1" to one end (Fig. 229, B). (3) By partially split- 
ting both ends, twisting the split portions and suturing them to themselves 
and laterally to the opposite end (Fig. 230, C). (4) By distance suturing, 
or bridging, with catgut; — The ends are approximated by lateral knotted 
sutures, as far as possible, then a continuous catgut suture is run back and 
forth between the ends and between the lateral knotted sutures, partially filling 
in the gap by catgut strands, upon which lymph and blood are poured, and, 
together with the catgut, organized (Figs. 237 and 238, B and C; and Fig. 
243, C). (5) Tendon lengthening by means of interposed silk sutures (Lange's 
method); — If the end of a severed tendon is not long enough to reach to the 
opposite end of the tendon, or to the site cf its periosteal insertion, it may be 
attached to this opposite end, or periosteum, by means of one or more stout silk 
sutures introduced in the fashion of a mattress suture. Experience has shown 
that tendon will form along this intervening silk and thus continue the con- 
tinuity of the tendon. Especially careful technic has to be employed, as septic 
infection is likely to invalidate the result. Four strands are used in ordinary 
tendons — and eight to twelve in tendons the size of the quadriceps extensor. 
The silk, which is stout, is boiled in 1-1000 bichloride of mercury solution. 
With a long, straight needle, the silk is introduced in the manner illustrated 
in Fig. 240. When the knot is tied tightly, the pull comes squarely from the 




Fig. 240. — Lange's Method of Tendon-lengthexing by Means of. Interposed 
Silk Sutures: — The method of introducing the suture is here shown in the case of a small 
tendon. Several sutures are used in larger tendons, evenly distributed throughout the substance 
of the tendon. 

points of emergence of the silk from one end of the tendon, to the points of 
entrance into the opposite end, directly in the long axis of the tendon. A drain 
for forty-eight hours is used, to carry off the fluids of the wound. Following the 
union of the tendon-ends, the tendon-sheath, if it have been incised or other- 
wise injured, is repaired with catgut sutures, as far as possible. In exposing 
the tendon, the sheath should not have been needlessly freed, for the vessels 
of the tendon reach it through the sheath. The overlying muscles are brought 
together with buried catgut sutures. The skin-wound is then closed — and the 
limb immobilized upon a splint, which will insure relaxation of the part. Pas- 
sive and active motion should be begun as soon as sound healing has occurred. 

Comment. — Many of the methods of nerve-lengthening are equally 
applicable to tendon-lengthening (pages 163 to 165). Not only may 
tendon-lengthening be accomplished by processes of plastic elongation in the 
sense of bringing into position undetached portions of tendon — but elongation 
may be also accomplished by the interposition of tendon substance, in those 
cases where the gap is too long to be bridged by other means, as in the similar 
operation for nerve-lengthening. The two most ordinary ways are the 
following; — (a) A piece of tendon of the required length and as nearly the 
desired size as possible, taken from a human being just operated upon, or 



TEXDOX-LEXGTHEMXG. 



259 



from a lower animal, is inserted into the interval between the severed ends, 
which have been freshened, and is sutured to both ends of the main tendon 
by longitudinal peripheral sutures, or other method (Fig. 239, D). (b) Half 
the thickness, and as much of the length as required, of part of the same or 
of one of the neighboring tendons of the patient is taken, and sutured, as 




Figs. 241-243. — Tendon-lengthening: — A, Poncet's accordion method (in case of tendo 
Achillis) — incisions partly across tendon; B, Same, showing amount of lengthening by traction 
upon tendon; C, Bridging with gut, reinforced with decalcified bone-cylinder. 

above, into the gap. The wound is treated as after other forms of tendon- 
lengthening. The interpolated tendon probably disappears, as such, after 
serving as a framework. 



TENDON-SHORTENING. 

Description. — The shortening of a tendon for the purpose of increasing 
the action of a muscle which has become impaired by the elongation of its 
tendon, — or for the purpose of improving a deformity (as the shortening of 
the tendo Achillis for talipes calcaneus). 

Operation. — Having exposed the involved tendon, its shortening may be 
accomplished in one of several ways; — (r) By excision of a piece of the tendon, 
with the union of the resulting ends by one of the methods of tenorrhaphy. 
(2) By oblique- division of the tendon, followed by gliding of the ends in such 
a way as to lessen the length of the tendon, and the suturing of the ends as 
in Fig. 244, A. (3) By division and shortening of the tendon, followed by 
the beveling of one end into a wedge, and the splitting of the other end — and 
the suturing of the wedge into the split portion, thus using up the excess of 
length (Fig. 246, C). (4) By the figure of Z method (Fig. 245, B); — make 
a vertical incision down the center of the tendon from F to K, and transverse 



20O OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

ones along E F and K L. Having drawn the cut portions apart, shorten each 
piece by removing the ends at G H and I J. E F and G H are then sutured 




Figs. 244-247. — Tendon-shortening: — A, Portion of tendon excised obliquely and sev- 
ered portions sutured end-to-end, in direct contact or overlapping (reverse of Fig. 225, B); B, 
Z-shaped incision is made, followed by excision of E F G H and I J K L, after which E F is 
sutured to K L: C, Following excision, ends of tendon are sutured in form of mortise; D, Ex- 
cision of portion of tendon by transverse incision, followed bv mattress-suturing of opposite 
ends (portion between circular transverse incisions is here excised). 

together, and I J and K L — as well as the vertical line of division. The wound, 
following the operations for tendon-shortening, is closed and treated as after 





Fig. 248. — Hoffa's Method of Tendon-shortening: — A, The manner of inserting the 

through-and-through suture. 
Fig. 249. — B, The appearance of the tendon after the tightening and knotting of the suture. 



TENDON-GRAFTING. 



261 



tendon-lengthening. Another form of tendon-shortening is shown in Fig. 247, 
D, where a portion of tendon is removed. (5) A tendon may be shortened 
by passing through its substance, lengthwise, two stout silk sutures after the 
fashion of the cords in Venetian blinds (Fig. 248, A) — traction upon which, 
and knotting will produce the shortening shown in Fig. 249, B, Hofta's method. 

TENDON-GRAFTING. 

Description. — Tendon-grafting, tendon-transplantation, or tendon-im- 
plantation, as the operation is variously termed, is the attachment of the 
distal end of a divided tendon into a neighboring sound tendon of the same 
general group or function. The attachment is sometimes made laterally, 
without the division of the involved tendon. A limb may be tunnelled and a 
tendon of one group drawn entirely through the limb and sutured to a tendon 
of another group on the opposite aspect. 

Indications. — (1) Those cases in which so much of the tendon has been 
destroved that its reconstruction is impossible — and the damaged tendon 




Fig. 250.— Tendon-grafting :— Of sound extensor of great toe into impaired anterior tibial ; A, 
Tendon of tibialis amicus; B. Proximal end of extensor proprius hallucis, which has been severed 
from lower end, C, and engrafted upon anterior tibial tendon; D, Innermost tendon of extensor 
brevis digitorum. 



is therefore grafted to a neighboring tendon (for instance, should one of the 
four tendons of the flexor sublimis or profundus digitorum be too extensively 
damaged for union of the proximal and distal ends, its distal end may be 



262 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

attached to one of the neighboring sound tendons of the same muscle). (2) 
Those cases in which a group of muscles, or a single muscle, has been para- 
lyzed — and one or more of the tendons of the paralyzed group is therefore 
grafted to a tendon of an unparalyzed group (for instance, if the tibialis 
anticus were paralyzed and the extensor propius hallucis intact, the tendon 
of the latter may be grafted upon the tibialis anticus) (Fig. 250). Where the 
tendon of the muscle from which the power is to be derived is of comparatively 




Figs. 251-254. — Tendon-grafting : — I. — Where the tendon of the muscle supplying the 
power is of comparatively little importance (shown on the right, in light), the entire sound 
tendon is grafted upon the impaired tendon (shown on the left, in dark). (Modified from 

Vulpius.) 




Figs. 255-259 — Tendon-grafting: — II — Where the tendon of the muscle supplying the 
power is of greater importance (shown on the right, in light), only a portion of the sound 
tendon is grafted upon the impaired tendon (shown on the left, in dark). (Modified from Vulpius.) 

little importance functionally, and the paralyzed muscle is of more importance, 
the entire sound tendon may be diverted into the paralyzed muscle (Figs. 
251-254). But where the tendon of the muscle which is to supply the power 
is more important than the paralyzed tendon, then but a portion of the sound 
tendon should be diverted into the paralyzed one (Figs. 255-259). 



OPERATION FOR UNITING TENDON TO PERIOSTEUM. 



263 



Operation. — Having exposed the field of operation by an incision harming 
the adjacent structures as little as possible, and having isolated the involved 
and the sound tendons, the technic of grafting may be accomplished in one 
of several ways — the chief of which will be here mentioned; — (a) Tendon- 
grafting by lateral attachment : — In the case of a divided tendon, the 
distal end is freshened by an oblique paring (Fig. 260, A). In the case of a 
paralyzed (undivided) tendon, it is divided obliquely (also A, Fig. 260). 
That portion of the sound tendon to which the involved tendon is to be at- 
tached is freshened upon its lateral aspect — to which the obliquely divided 
distal end of the injured, or paralyzed, tendon is now sutured with gut by 
peripheral coaptation sutures, or other form of suturing. Sometimes the 
paralyzed tendon is not divided, but its lateral aspect freshened, just as in 
the case of the sound tendon — these aspects being then brought together 
and sutured (Fig. 261, 
B). Especially would 
this be indicated where it 
is possible for the struc- 
ture of the paralyzed 
muscle eventually to re- 
gain its functioning, (b) 
Tendon - grafting by 
implantation : — The 
sound tendon is split en- 
tirely through its center, 
over an area sufficiently 
long to accommodate the 
tendon to be grafted. 
Freshen the distal end 
of the involved tendon 
(injured or paralyzed) 
by paring both sides in 
a beveling or wedge- 
shaped fashion. The 
wedge-shaped piece of 
tendon is then inserted 




between the lips of the 
split tendon and held in 
place by two or more 



Figs.260-262.— Tendon-grafting :— A, Grafting end of di- 
vided tendon into lateral aspect of undivided tendon ; B, Grafting 
undivided tendons laterally; C, Implantation of beveled end of 
tendon between the split portions of sound tendon. 



gut sutures passed trans- 
versely through both tendons (Fig. 262, C). The wound is finally closed 
in the usual way — and the limb put up upon a splint in such a position as to 
secure relaxation of the parts. 



OPERATION FOR UNITING TENDON TO PERIOSTEUM. 

lange's method. 

Description. — It sometimes happens that the end of a divided tendon can 
not be made to reach its normal site — it is then to be sutured either to a neigh- 
boring tendon or into adjacent periosteum or bone, as near to its original 
insertion as possible. In the case of uniting it to the periosteum, the technic 
is as follows: — a flap of periosteum, from 1 to 2 cm. ({ to f inch) in length 
is detached with periosteal elevator, in convenient relationship to the tendon. 



264 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

The end of the tendon is then cut obliquely in such a way as to present a favor- 
able surface, and this freshened surface is sutured with fine chromic gut to the 




Fig. 263. — Lange's Method of Uniting Tendon to Periosteal Flap. 

outer surface of the periosteal flap. The neighboring soft parts are brought 
normally about the site of operation, buried sutures being used where indicated 
— and the wound closed. (See Fig. 263.) 




Fig. 264. — Wolff's Method of Implanting Tendon into Bone. 

OPERATION FOR UNITING TENDON TO BONE. 
wolff's method. 

Description. — Instead of uniting the end of the tendon to periosteum as' 
in the operation just given, the tendon may be implanted within the bone and 



REPAIR OF RUPTURED OR DIVIDED TENDON-SHEATHS. 



*5 



surrounded by the periosteum. The periosteum is incised over the site where 
the end of the tendon is to be implanted. After having retracted the two lips 
of the incised periosteum, a groove is chiselled in the exposed bone. The 
bevelled end of the tendon is buried in this groove — and the margins of the 
periosteum are sutured to the implanted tendon and to each other. The 
wound is closed without drainage, unless otherwise indicated. (Fig. 264.) 

TRANSPLANTATION OF TENDON WITH ITS OSSEOUS INSERTION. 
Description. — It occasionally happens, after fracture of the patella 
(especially when repair is not undertaken until after contracture has taken 
place) and after rupture of the tendon of the quadriceps extensor or the tendo 
Achillis, that it is impossible to approximate the fragments of bone, or ends of 
the tendons, without the transplantation proximally of the osseous prominences 
into which the tendons are inserted. Let it be supposed that the quadriceps 
extensor tendon has been ruptured a short distance above the patella; — 
When the site of rupture is exposed, it is found impossible to bring the ends of 
the tendon together. The vertical incision for its exposure is continued down- 
ward. The patella, ligamentum patella?, and tibial tubercle are exposed. The 
tibial tubercle is now chiselled from the tibia — and any adhesions which bind 
the parts down are freed. The ruptured extensor tendon is now sutured — 
during which the separated tibial tubercle has glided upward upon the tibia 
into a new position. In this higher position upon the anterior aspect of the 
tibia, sufficiently far below the upper margin of the tibia not to interfere with 
the joint-movement, a steel nail is driven through the tibial tubercle — a nail 
sufficiently long to be left protruding through the skin to be removed after union 
is complete. The soft parts are then closed about the nail — as well as over 




Fig. 265. — Transplantation of Tendon with its Osseous Insertion. 

the site of the ruptured tendon. This same technic may be applied to the 
tendon of the triceps. (Fig. 265.) 



REPAIR OF RUPTURED OR DIVIDED TENDON-SHEATHS. 

Description. — A tendon-sheath may be accidentally ruptured by violent 
action or injury, as in the case of the long head of the biceps, or may be pur- 
posely divided in an operation temporarily to expose the tendon within, or 



266 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

the underlying parts beyond (as the division of the sheath of the tendo Achillis 
for tenorrhaphy, or the division of the common sheath of the peroneus longus 
and brevis tendons temporarily to retract the contained tendons in the excision 
of the ankle-joint). 

Operation. When the object is to expose the tendon and sheath alone, 
a slightly curved incision is made, coming over the sheath above and below 
but somewhat to one side at the site of rupture (so that the cicatrices of skin 
and sheath will not fall directly over each other). Or a straight incision 
may be made directly over the tendon-sheath. When the sheath is divided 
in the course of some other operation, the position of the incision will have 
been determined by the special operation. The part is then put into that 




Fit 



266. — Excision of Tkndon-sheath : — Sheath is seized with forceps and divided circularly 
around the tendon at both ends of the involved area. 



position which will relax the tendon to the greatest extent — the tendon and 
sheath are then clearly located, and the former placed within the latter, 
while the edges of the sheath are held aside. The sheath is then carefully 
dropped together over the tendon and the sheath-margins sutured with a 
fine continuous gut suture. The wound is now closed and the limb put up 
so as completely to relax the tendon. In about ten days the limb is taken out 
of the splint at intervals and passively moved, to prevent adhesion of tendon 
to sheath — while the surgeon's left thumb placed over the tendon during 
manipulation holds it in place within the sheath and relieves part of the 
strain upon the recently sutured sheath. 

Comment. — In cases of paralysis, the peroneus longus has been grafted 



EXCISION OF TEXDOX-SHEATHS. 267 

into the tendo Achillis, into the tibialis posticus, and even into the tibialis 
anticus; — the tibialis anticus into the extensor proprius haUucis; — the sartorius 
into the rectus femoris, and the like. Tendons are sometimes approximated 
by tunneling under other structures. 

EXCISION OF TENDON-SHEATHS. 

Description. — The removal of more or less of the sheath of a tendon. 
Generally resorted to in cases of obstinate tenosvnovitis. 

Operation. — The special tendon-sheath involved is exposed by an incision 
directly over it, — or by an incision beginning and ending over the sheath but 
passing to one side of the sheath throughout the rest of its course, thus en- 
abling a skin-flap to be turned to one side, so that when replaced its scar 
will not fall directly over the tendon. Having retracted the soft parts, the 
tendon-sheath is entirely isolated, with care, from the neighboring structures — 
especially from those forming its bed. The sheath of the tendon is now 
divided circularly around the tendon, above and below the diseased portion 
— but without cutting the tendon itself. Having completed the two circular 
incisions at either end, the sheath is split in the long axis of the tendon— 
and thus laid completely open — and may be removed in one piece (Fig. 266). 
Any diseased portions of the contained tendon found, should be scraped. 
The skin-flap is then united — and the limb put up so as to immobilize the 
tendon. 



CHAPTER IX. 



OPERATIONS UPON THE LIGAMENTS. 

SYNDESMOTOMY. 

Description. — Division of ligaments. Generally performed for the con- 
traction of ligaments occurring as the cause, in whole or in part, of some 
of the deformities. 

Operations. — The ligament, or ligaments, at fault may be divided by 
the subcutaneous or open method — the latter being preferable. In the open 
method the involved ligaments are exposed by the simplest and safest route 
— and divided in the same general manner as the division of tendons by the 
open method — and the wound similarly treated. 



SUTURING OF LIGAMENTS. 

The suturing of ligaments is performed upon the same general principles 
as is tendon-suturing (see page 251). 



LENGTHENING OF LIGAMENTS. 

Description. — Lengthening of ligaments which have become shortened 
through disease or injury — especially in cases of deformity. 

Operation. — Many of the same methods involved in tendon-lengthening 
are applicable to the lengthening of ligaments. Where a ligament is attached 
to a bony prominence, this has been chiseled off and displaced to a neigh- 
boring site and there nailed (as in the case of the ligamentum patella?, where 
the tubercle of the tibia has been displaced to the upper portion of the tibia 
— but with uncertain success). (See Tendon-lengthening, page 254.) 



SHORTENING OF LIGAMENTS. 

Description. — Shortening of ligaments which may have become lengthened 
through disease or injury. 

Operation. — Many of the tendon-shortening methods may also be ap 
plied to elongated ligaments. As in the above operation, where a ligament 
is attached to a prominence of bone, this may be chiseled from its normal 
site and nailed to an adjacent site (as in the case of the ligamentum patellae, 
where the tibial tubercle has been displaced lower down the tibia). 

Note. — Most of the work done upon Ligaments will be found described 
in special writings upon orthopedic surgery. (Also see Tendon-shortening, 
page 259.) 

268 



CHAPTER X. 

OPERATIONS UPON THE FASCIA. 

FASCIOTOMY OR APONEUROTOMY. 

Description. — Fasciotomy or aponeurotomy signifies the division of 
bands or planes of contracted fascia. The term is used with especial reference 
to operations upon contracted palmar and plantar fascia, in the deformities 
of those parts — and in connection with the contracted fascia lata, and the 
contracted fascia following burns, and the like. 

Operation. — The division is usually accomplished by the subcutaneous 
or open method. The general principles of the operations will be here de- 
scribed — the steps of the special operation will be determined by the anatomy 
and contraction of the part involved, (a) Fasciotomy by the Subcutaneous 
Method : — Where the contracted fascia is in the form of narrow bands, a 
sharp-pointed tenotome with a narrow cutting-edge (of about 6 mm., or J 
inch) is best. Where the fascia is contracted in the form of planes, a sharp- 
pointed tenotome with a longer cutting-edge is to be preferred. The short- 
bladed fasciatome, however, is the safer form of tenotome, as far as damaging 
the neighboring structures is concerned. The instrument is inserted flatwise 
beneath the fascia — the cutting-edge is then turned toward the contracted 
fascia, which is rendered further prominent by extending the part, and the 
special band of fascia is divided against which the knife-edge presses — then 
another band is sought — new bands appearing to spring into existence as 
others are cut — the tenotome being carefully pushed in different directions 
until all the bands are cut. Just before each band is cut, the tip of the surgeon's 
left forefinger should be placed over the tense band of fascia and make counter- 
pressure, and thereby serve as a guide of the progress of the knife toward the 
skin. Sometimes all the bands can be divided through one introduction 
of the tenotome — in other cases the tenotome is introduced at several sites. 
The tenotome is sometimes introduced between the skin and the fascia and 
divides the latter by cutting downward, which is somewhat more risky. 
When all or nearly all of the ligaments have been divided which the tenotome 
can detect and reach, the part is fully extended, breaking down the remaining 
ones if any. The tenotome wound or wounds are then closed by a suture 
or two and the limb immobilized in a splint, which is worn for a long period. 
(b) Fasciotomy by the Open Method : — A number of limited incisions 
may be made from without inward, through the skin and fascial bands, — 
or the involved fascial bands may be exposed through a skin-flap which is 
raised and retracted to one side, or through a long straight incision whose 
margins are retracted laterally. Following the thorough exposure of the 
parts, in the last method, the contracted fascia is dissected out wherever 
present. In either one of the open methods, the part is fully extended after 
the operation, the skin-wound closed and the part immobilized. 

Note. — Much of the work done upon the Fascia will be found described 
in special writings upon orthopedic surgery. 

269 



CHAPTER XI. 

OPERATIONS UPON THE BURSAE. 

PUNCTURE OF BURSAE. 

Description. — Generally resorted to for exploring the nature of the 
bursal contents, or for injecting fluid for destroying its secreting surface, or 
simply for the evacuation of its contents. 

Operation. — The needle of the syringe is introduced, with the usual 
precautions, into the interior of the enlarged bursa — piercing the skin as 
directly over the. cyst as possible and passing by the safest route through, or 
preferably between, the overlying tissues. The site of the introduction will 
depend upon the special bursa. 

INCISION OF BURSAE. 

Description. — Usually resorted to for the evacuation of pus, or other 
fluid; or to expose the interior for curettage. 

Operation. — An incision is made down to the bursal sac — selecting a 
site where the least important structures will be encountered and the sac 
most readily reached. The intervening parts having been retracted to one 
or both sides and the bursa steadied by the surgeon's left forefinger and 
thumb, its wall is incised with a scalpel — after which the special object of 
the operation is accomplished. The steps of the operation will depend upon 
the special bursa. In some cases the incision will pass from the skin directly 
into the bursal cavity, without any intervening dissection. 

EXCISION OF BURSAE. 

Description. — Generallv done for the removal of chronically inflamed 
or diseased bursa? — the majority of the latter cases being tubercular. 

Operation. — The exposure of the enlarged bursa is accomplished as 
described under the operation for incision. The surrounding parts having 
been then drawn well aside, the entire bursal sac is dissected from its bed, 
partly by blunt and partly by sharp dissection — carefully guarding the neigh- 
boring structures, and especially those joints with which the bursa may 
communicate. Whenever possible, the communication with a joint should 
be closed by suturing together the edges of the neck of the excised bursa. 
The wound is then closed, or drained, as indicated. 



270 



CHAPTER XII. 

AMPUTATIONS, 

GENERAL CONSIDERATIONS. 

Definition. — Amputation — the removal of a limb through its continuity. 
Disarticulation — the removal of a limb at a joint. 

Indications. — Any injury, disease, or malformation rendering retention 
of the limb incompatible with life or comfort; — avulsion of limb; compound 
fracture; compound dislocation; fracture with great comminution of bone; 
laceration of important vessels; extensive contusion; extensive laceration; gun- 
shot injuries; aneurism; effects of heat and cold; gangrene; extensive bone 
disease; tumors; elephantiasis; tetanus; snake-bite; deformities. Amputa- 
tions are far less frequent in modern conservative surgery than formerly — 
limbs now being often saved by excision, and other operations, which were 
at one time sacrificed. 

Preparation of Patient. — The constitutional preparation of the patient 
— and the previous and immediate local antiseptic preparation of the part — ■ 
are the same as for any major operation. The part should be shaved, where 
its condition admits of this preparation — and should come to the table with 
the preliminary dressing in position. 

Position of Patient, Surgeon, and Assistant. — (i) Patient rests upon 
back, lying near side of table, and nearer the upper end for amputations of 
the upper extremity, that the limb may be held out from the table at a right 
angle; — and nearer the lower end for amputations of the lower extremity, 
that the limb may be held both out from the table, and also over the end of 
the table. (2) Surgeon so places himself as to enable him to grasp with 
his left hand the patient's limb between the saw-line and the trunk — which 
will place him upon the outer side of the right limbs, and on the inner side 
of the left limbs (between the table and the left limbs) (Fig. 267). This is 
the general rule, of almost universal application (and will not be repeated 
with each operation) — where exceptions occur they will be mentioned with 
the special amputations. In amputations of the upper part of the left arm 
and upper part of the left thigh, especially the latter, it may be more con- 
venient to stand to the outer side of the limb, in which case the left hand 
grasps the limb below the saw-line. This avoids wedging one's self between 
the table and the upper part of the limb, which, in the case of the lower limb 
particularly, cannot be stretched out at a right angle from the table. (3) As- 
sistant : — grasps the part of the limb, wrapped in an aseptic towel, that is 
to be removed, standing facing the surgeon, so that he can better steady the 
limb against the movements of the saw than if he stood at the end of the 
limb — his arms being thus parallel rather than at a right angle to the working 
of the saw. 

Instruments. — Esmarch's rubber bandage and tourniquet; amputating 
knives, long and short; scalpels, various; cartilage knives; Catlin knives; 
saws, ordinary amputating, bow, and butcher; small thin saw, for spicule 
of bones; periosteal elevators; metallic retractors (for flaps); linen retractors 

271 



2 7 2 



AMPUTATIl >\S. 



(for flaps); broad metallic or ivory spatula? and retractors to hold soft parts 
out of way; dissecting and toothed forceps; artery-clamp forceps, numerous; 
rongeur forceps; scissors, straight and curved, sharp and blunt; tenacula; 
probes; grooved directors; ligatures and sutures, silk, catgut, plain, chro- 
mic, silk-worm gut, tendon; needles, straight and curved; needle-holder; 




Fig. 267. — Illustrating Position of Surgeon in Amputating: — Standing to outer side 
of right and to inner side of left limbs — manipulating knife with right hand, and steadying limb 
(also retracting soft parts) with left hand placed between saw-line and trunk. — Hands of assistant 
are shown in various positions, grasping and supporting part to come away. This may be taken 
as a bird's-eye view of patient in dorsal decubitus. 

drainage-tubes; irrigator and irrigation fluid; normal salt solution and instru- 
ments for intravenous infusion; dressings for stump; splint. Special instru- 
ments will be mentioned under special amputations. 

Anesthesia in Amputations. — While general anesthesia (preferably nitrous 
oxid and ether) is ordinarily used in amputations, spinal analgesia and neural 
infiltration may be used where especially indicated (where, for instance, 
general anesthesia is contraindicated) . 

Control of Hemorrhage in Amputations. — Hemorrhage may be con- 
trolled in one of two general ways — by some form of tourniquet or constrictor 
or by digital compression. (A) Control of hemorrhage by tourniquet 



GENERAL CONSIDERATIONS. 



273 



or constrictor: — Several forms of tourniquet control are in use; — (1) 
Esmarch's Broad Rubber Bandage, and Tourniquet of Rubber Tubing or 
Narrow Band; — These constrictors may be used in two ways; — (a) Use of 
Bandage and Tourniquet (Esmarch Method) ; — The bandage is applied 
from the fingers or toes upward, for example, nearly to the shoulder or hip 
— the tourniquet is then applied above the bandage — and the bandage re- 
moved. This saving to the patient of the blood in the limb is more particu- 
larlv indicated when the limb is healthy and the patient anemic — otherwise a 
patient who loses a limb can also generally afford to lose its proportional amount 




Fij;- 268.— Illustrating Methods of Hemorrhage Control:— Wyeth's method by rubber 
tourniquet and needles, at right shoulder-joint.— Same at left hip-joint.— Ordinary rubber tourniquet 
and pad at left shoulder-joint, reinforced (kept from slipping) by strips of roller-bandage. — Same, at 
right hip-joint.— Use of Esmarch rubber tourniquet above left elbow.— Exsanguination of limb by 
Esmarch rubber bandage, followed by application of rubber tubing 1 or Esmarch rubber tourniquet) 
above left knee. — Compression of right femoral by Petit type of tourniquet.— Preliminary ligation 
of left femoral. — Digital compression of main arteries at right wrist. 



of blood. (Fig. 268, left leg.) (b) Use of Esmarch's Tourniquet Alone;— The 
limb is held elevated for about three minutes (this empties the veins mechani- 
cally and causes the arteries to contract reflexly, thus lessening the blood to the 
limb; but if the elevation be too long, the arteries recover, dilate, and let in 

18 



274 AMPUTATIONS. 

more blood) — and, during the time of this elevation, a healthy limb may be 
massaged downward to aid exsanguination — the tourniquet alone is then 
applied as high up the limb as indicated for the special operation, no form of 
bandage having been previously applied (Fig. 268, left arm). In operating any- 
where below the elbow or knee, the constriction should be applied just above the 
elbow or knee, — and in amputating anywhere above the elbow or knee, the con- 
striction should be applied as near the trunk as possible. This is the general 
method of hemorrhage control in the majority of cases. The objections 
which have been urged against the Esmarch bandage and tourniquet, or 
tourniquet alone, are — the increased bleeding following the operation, from 
temporary vasomotor paralysis; the possible lowered vitality of the com- 
pressed parts; occasional temporary paralysis of nerve-trunks from pressure; 
and the possibility of forcing pathological products into the body. The 
great advantage over these disadvantages, however, is that it controls all 
bleeding — and its use, therefore, is advisable in spite of the disadvantages. 
(2) Tourniquet of the Petit Type; — The entire limb is compressed, with 
special pressure over the main artery (Fig. 268, right thigh). (3) Tourniquet 
of the Signorini Type; — No circular constriction is used — a pad on one arm 
of the tourniquet compresses the artery against a counter-pad on the other 
arm of the tourniquet opposite or beneath the limb or body. (B) Digital 
compression of the main artery : — Compression is generally made through 
the skin — but may be made directly upon the main vessel through an incision 
made immediately over it. (Fig. 268, right hand.) The office of hemorrhage- 
control by digital compression is sometimes delegated to a single individual 
in a hospital. Note : — Special methods of controlling the circulation will be 
mentioned in connection with special amputations, especially those about 
the shoulder- and hip-joints (Fig. 268, shoulders and hips). Also see dis- 
articulations at shoulder and knee (pages 374 and 433). 

THE GENERAL TECHNIC IN AMPUTATING. 
LOCATION OF LINE OF BONE-SECTION, OR DISARTICULATION. 

The determination of the saw-line in an amputation, or the disarticula- 
tion-line in a disarticulation, is the first step — generally marking the upper 
limit of the operation — and is the necessary guide to the subsequent steps. 

Level at Which the Bone, or Bones, are to be Sawed. — Is to be deter- 
mined by the individual case — and its position should be such that enough 
healthy tissue will be provided for, between the saw-line and the upper limit 
of the diseased or injured tissues to be removed, to furnish ample covering 
of soft parts to protect the stump without undue tension. 

Level of Joint-line at which Disarticulation is to be Done. — The 
position of the articulation-line is, of course, fixed — it is only necessary to 
recognize it anatomically — and to determine whether sufficient sound tissue 
intervenes between joint-line and upper limit of the parts to be removed to 
afford covering satisfactory in quantity and quality to protect the stump. 
Otherwise the disarticulation will have to be converted into an amputation 
at a higher level. 

Relation of Saw-line to Length of Flap, and Vice Versa. — While 
the position of the saw-line determines the amount of tissue (and, conse- 
quently, length of flap or flaps or of circular covering) which will be required 
to cover the sawed bone — so also does the choice of the method of amputation 
to be used largely determine the amount of bone to be sacrificed (and, con- 
sequently, the length of the resulting limb) — for (a), In circular amputations 



LOCATK >N < >F LIMITS OF SKIN INCISIONS. 



275 



and amputations by equal flaps, the minimum amount of bone is sacrificed; 
and (b), In amputations by a single flap, the maximum amount of bone is 
sacrificed. 

LOCATION OF LIMITS OF SKIN INCISIONS. 

A total covering of soft parts equivalent to ih diameters of the limb at 
the saw-line is the general rule of allowance. It is necessary, therefore, to 
determine the lower limit of the skin incision, as this forms the lower limit 
of the total covering. This limit may be determined accurately or approx- 
imately. 

In Circular Amputations. — (a) Accurately; — Find the circumference of 
the limb at the saw-line by means of a metallic tape-line (say, 15 cm., or 6 
inches) — one-third of the circumference will give the diameter (say, 5 cm., 
or 2 inches). Therefore, to furnish ih diameters (say, 7.5 cm., or 3 inches) 
the lower limit of the skin incision would have to be 3.8 cm., or 1^ inches, 
below the saw-line, (b) Approximately; — Place the thumb at the saw-line 
on the anterior aspect of the limb (the nail facing the junction of the limb 
with the trunk) and the tip of the index-finger immediately opposite on the 
posterior aspect of the limb (without compressing the soft parts). Xow, 
keeping the thumb where first placed, and keeping the distance between 
the tip of the thumb and tip of the index unchanged, rotate the hand around 
(making these two fingers act as the two arms of callipers) until the tip of 




Fig. 269.— Relation of Skin Incision to Saw-line: — Methods of amputation by equal 
flaps, circular covering, and unequal flaps are shown each to furnish a covering of \ l ,' 2 diameters of 
limb at saw-line. 

the index rests upon the anterior aspect of the limb in a vertical line below 
the tip of the thumb. The distance between the thumb-tip and the finger-tip 
will be the diameter of the limb at the saw-line — and three-fourths of this 
measurement will insure a covering of the requisite \\ diameters of the limb. 
In calculating the covering in the circular method of amputating, it is to be 
remembered that as the circular covering will be sutured in a straight line. 
either from before backward or from side to side, practically the covering 
may be regarded as being furnished by two aspects of the limb, either the 
front and back or the two sides — that is, as though furnished by two equal 
flaps (Fig. 269). 

In Equal Flap Amputations. — Same as for the circular method, whether 
calculated accurately or approximately (Fig. 269). 

In Unequal Flap Amputations. — (say the anterior twice as long as 
the posterior flap) ; — (a) Accurately; — Finding the circumference and diameter 
in the above manner (the measurements being as there given) — the lower 
limit of the anterior flap would be 5 cm. (2 inches) below the saw-line, and 
the lower limit of the posterior, 2.5 cm (1 inch) below, (b) Approximately; — 
Having gotten the measurement of the full diameter marked out on the 



276 



AMPUTATIONS. 



anterior aspect, as explained above, this will represent the length of the 
anterior flap — and one-half of this measurement will give the length of the 
posterior flap (Fig. 269). 

INCISION OF SKIN AND FASCIA. 

In general terms, it is considered that the aspects of the limb furnish an 
average covering of 1^ diameters of the limb at the saw-line — whether this 
covering consist of skin alone, or of skin and muscle combined — and whether 
furnished by one or more aspects of the limb. In the circular method of 
amputating, the covering is furnished equally from all aspects of the limb. 
In the method by equal flaps, it is furnished equally by two aspects of the 
limb. And in the method by unequal flaps, the inequality of length may 
be parceled out in any way indicated, just so the total covering is equivalent 
to ih diameters at the saw-line. If the covering be from one aspect alone, 
as in the single flap or in the elliptical methods, the total diameter and a half 
comes from that one aspect. Where the amputation is done through a site 
of maximum contractility of skin and muscles (as through the lower half of 




Fig. 



:7c— Incising Skin and Fascia in Circular Amputation: — I, Position of long knife in 
incising upper, further and part of lower aspects of limb. 



the arm, or the lower half of the thigh), a somewhat greater allowance may 
become necessary (even to the extent of two diameters). Where the ampu- 
tation is done through a site of minimum contractility of skin and muscles 
(as through the dense tissues of the palm of hand and sole of foot), a somewhat 
less allowance than the average may be provided. 

Manner of Incising Skin and Fascia in Circular Amputations. — 
Whether a stump is going to be covered by skin alone, or by skin and muscle, 
the skin is invariably cut first and cut separately. Standing to the outer 
side of the right and inner side of the left limbs, grasp the part above the level 
of the skin incision with the left hand and retract the skin upward, either 
entirely alone or aided by an assistant (the assistant's aid being more necessary 
in large limbs) — the retraction being evenly maintained throughout. This 
is done to provide as ample a skin covering for the muscles as possible, for, 
as the average contractility of the skin involved in an amputation is greater 



INCISION OF SKIN AND FASCIA. 



277 



than the average contractility of the muscles involved, if the skin and muscles 
were divided on the same level it would subsequently be found difficult, or 
impossible to make the skin meet over the cut muscles. Therefore this 
circular division of skin, which has been well drawn up under the knife-cut 
prior to incising, means an actual division of the skin a little lower than the 
position of the knife on the limb indicates — but insures having a somewhat 
fuller measure of skin than if it were cut without retraction. Having thus 
retracted the skin, take a long knife with a blade one-and-a-half times the 
diameter of the limb to be removed — and, holding it in a full hand, like a 
pruning-knife, pass the arm under the patient's limb and bring the cutting- 
edge into contact with the upper surface of the limb, the back of the knife 
being horizontal and pointing upward, the heel of the knife being over the 
center of the limb, and the point projecting beyond the limb toward the 
surgeon. Beginning the incision with the heel of the knife, steadily and 
evenly draw the knife from heel to point, passing with one sweep of the knife 




Fig. 271— Incising Skin and Fascia in Circular Amputation : — II — Position of I01 
incising nearer and remainder of lower aspect of limb. 



through three-fourths of the circumference (Fig. 270). The knife is then with- 
drawn and reinserted with its heel at the place of beginning of the incision 
on the supero-external surface (in operating on the right limbs), and, with 
one sweep, passes through the remaining fourth of the circumference 
(Fig. 271). The attempt to make the complete circuit with one sweep is 
not to be recommended, as the ends of the resulting wound are not apt to 
be in line, and the wound, generally, imperfectly made. This circular skin 
incision is sometimes made with a small knife. The assistant can aid the 
surgeon by rotating the limb to meet the knife. The blade is held perpen- 
dicular to the skin throughout. The incision passes through skin and fas- 
cia, but not into muscles. Owing to the unequal retraction which some- 
times takes place upon the different aspects of a limb, it may be necessary 



278 



AMPUTATIONS. 



to plan one portion of the circular incision upon a lower level than the rest 
of the incision — this greater allowance of skin at this site will, however, be 
drawn up on a level with the rest of the circular incision, owing to the 
greater retraction there. So that what may appear as an oblique incision, 
will become circular and upon the same level after the division. 

Manner of Incising Skin and Fascia in Flap Amputations. — As in 




Fig. 272.— Incising Skin and Fascia in Flap Amputation: — I — In cutting rounded flaps. 




Fig. 273.— Incising Skin and Fascia in Flap Amputation :— II — In cutting rectangular flaps. 

the circular method, whether the covering is to be of skin alone, or of skin 
and muscles, the skin is invariably cut first and separately — and whether 
the flap be cut from without inward, or from within outward (by transfixion). 
The preliminary steps, as to position, retraction of skin, and general prin- 



FREEING SKIN AND FASCIA. 279 

ciples involved, are the same as in making the skin incision in the circular 
amputation. When all is ready, the surgeon takes an ordinary scalpel of 
medium size, and, holding it as a violin-bow, enters its point into the skin 
vertically, at the upper limit of the base of the flap. The knife passes through 
skin and connective tissue, and as it travels vertically down one limb of the 
flap the cutting-edge is lowered until it forms less than a right angle with 
the surface being cut — when nearly the lower limit of the flap is reached, 
the knife rounds the corner of the flap — thence passes transversely across 
that aspect of the limb from which the flap is being taken — then similarly 
rounds the opposite corner — and thence travels vertically upward to a point cor- 
responding with the point of beginning (Fig. 272). Care should be exercised 
that each flap should measure one-half the circumference of the limb at its base, 
and one-half of the circumference at that part of its free end just above the 
rounded corners — and that these corners should be very bluntly, and not 
sharply, rounded (that they should be squarely rounded, as it were), for if 
they be too much tapered at their free ends, the}' will cover the stumps with 
difficulty and unsatisfactorily. Instead of cutting the entire flap with one 
sweep of the knife, each vertical limb and one corner of the flap should be 
made with one downward cut of the knife. While all flaps should be prac- 
tically square, with merely the corners rounded, an exception is made in the 
method of unequal rectangular flaps of skin and fascia (Teale's method) — 
the corners of the flaps being here right-angled, instead of rounded (Fig. 
273). This is also the case in the conversion of a circular method of 
amputation into a flap method by two vertical incisions placed laterally — 
and even here the corners mav be rounded. 



FREEING SKIN AND FASCIA. 

Having incised skin and fascia, for either a circular or a flap amputation, 
the manner and extent of further freeing skin and fascia will depend upon 
whether the method is to be one of simply skin and fascial covering, or of 
skin, fascial, and muscular covering for the stump. 

Freeing Skin and Fascia in Simple Skin and Fascial Covering for 
Stump. — The skin and fascia, after having been divided, are partlv retracted 
and partly dissected back to the line of future division of muscles. The edges 
of skin and fascia (avoiding the separation of the one from the other, as the 
vessels reach the skin through the fascia) are grasped by the fingers of the 
left hand, lifted from the muscles, and drawn upward — and, while held in 
this position, and while under slight tension, the fascia is touched here and 
there at points where it especially binds along the line of its junction with 
the muscles and deep fascial planes, by a scalpel held at a right angle to the 
surface of the muscles and with its cutting-edge toward the part to be removed 
— and thus scoring of the skin and consequent damage to its blood-supply are 
avoided. The skin and fascia are, by this means, raised in one layer from 
the muscles — and the skin should be raised with all the underlying fascia 
possible — and the combined skin and fascia should be raised evenly up tc 
the future line of muscle division (Fig. 274). 

Freeing Skin and Fascia in Skin, Fascial, and Muscular Covering 
for Stump. — Special care is here taken not to separate skin and fascia from 
underlying muscles, any further than simply in the immediate line of original 
skin incision, and simply for the purpose of allowing of full retraction. The 
skin and fascia are here not picked up and separated from the muscles — ■ 



2 8o 



AMPUTATIONS. 



the only knife-touches necessary being a few where the fascia has not been 
thoroughly divided and where it is necessary further to divide a fascial attach- 
ment here and there in order that the skin and fascia may retract as far as 




Fig. 274.— Freeing Skin and Fascia from Underlying Muscles. 

they naturally will unaided by manual retraction — and this is done by touching 
the points of binding at the bottom of the original incision, by the point of a 
knife held vertically. 




Fig. 275. — Retraction of Skin and Fascia. 



RETRACTION OF SKIN AND FASCIA. 

Where Stump-coverings are to be of Skin and Fascia Alone. — Having 
freed skin and fascia from the underlying parts, as above described, partly 
by retraction and partly by dissection, until the line is reached at which the 
muscles are to be divided, the skin and fascia are further retracted above 



DIVISION OF MUSI l.KS IN CIRCULAR METHODS OF AMPUTATION. 281 

this line and are held out of the way by the hands of an assistant, or by re- 
tractors (Fig. 275). 

Where the Stump-coverings are to be of Skin, Fascia, and Muscles. 
— Retraction of skin and fascia from the underlying muscles, other than that 
which occurs unaided, is not practised. It is sought, on the other hand, to 
keep in contact, as one layer, skin, fascia, and muscles. 



DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. 

In the Ordinary, or Infundibuliform, Variety of Circular Amputa- 
tion. — (For description, see page 303.) — (a) Division of More Superficial 
Muscles; — The position of surgeon, manner of holding limb, kind of knife 
and manner of manipulating it, are all the same as in making the skin incision. 




Fig. 276.— Division of Muscles in Infundibular Variety of Circular Amputation: — I — Di- 
viding more superficial muscles on level with retracted skin and fascia. 

The skin and fascia having been circularly incised and allowed to retract, 
the surgeon grasps the limb above the naturally retracted skin, and further 
retracts skin and fascia, putting, at the same time, the muscles upon the 
stretch by this upward retraction of the overlying parts, aided by an assistant 
in the case of larger limbs. The more superficial muscles are now divided 
circularly on an exact level with the retracted skin, by one sweep of a long 
knife passing, first, through three-fourths of a circle, followed by a second sweep 
through the remaining fourth (Fig. 276). It is not always possible to divide 
only and wholly what are generally understood as the superficial layers of 
muscles — it is only meant that one divides, in this first circular division, about 
one-half of the muscular covering of the limb, the knife sometimes dividing 
a group of muscles completely and sometimes only partially. To allow for 
unequal retraction, the muscles may sometimes have to be divided lower 
on one aspect of the limb than on another, (b) Retraction of More Super- 



>S2 



AMPUTATIONS. 



ficial Muscles; — This layer of muscle tissue is now retracted as the skin was 
above it. It is not expected that the first muscle layer includes all and only 
the superficial muscles, and the deep layer all and only the deep muscles — 




Fig- 2/7- 



-Division of Muscles in Infundibular Variety of Circular Amputation :— II— 
Dividing deeper muscles on level with retracted superficial muscles. 



the former includes simply the more superficially placed, and the latter the more 
deeply placed muscles. There is no general use made of the scalpel in freeing 
the superficial muscle layer, as in the case of separating the fascia and skin 
from the muscles, but, where indicated, a touch of the knife may be used to 




Fig. 278— Division of Muscles in Cuff Variety of Circular Amputation— on a level with 
the turned-back cuff and fascia. 

enable the more superficial muscles to be evenly retracted, (c) Division of 
Deeper Muscles; — Having retracted the divided muscles more superficially 
placed, the more deeply situated muscles are now circularly divided on a 



DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. 283 
level with the retracted superficial muscles, and in a manner similar to the divi 




Fig. 279.— Division of Muscles in Modified Circular Amputation— showing flaps of skin 
and fascia turned back, the more superficial muscles divided, and the knife in the act of dividing the 
deeper muscles in the infundibular fashion. 

sion of the first layer (Fig. 277) . It is to be planned that this circular division 
of the deep muscles will come down 
upon the bone sufficiently far below the 
saw-line to provide for a periosteal flap, 
(d) Retraction of Deeper Muscles;— 
This is done preparatory to forming 
the periosteal covering. Note — it will 
thus be seen that, having divided skin 
and fascia lowest of all, the superficial 
muscles have been divided upon a higher 
level, and the deep muscles upon a still 
higher level — forming, thereby, when the 
bone is sawed, a hollow cone, whose apex 
will be formed by the sawed bone, whose 
base will be the margin of skin and 
fascia, and whose sides will be com- 
posed of the cut muscles (Fig. 302). 

In the Circular Amputation "a 
la Manchette," or Cuff Variety of 
Circular Amputation. — (For descrip- 
tion, see page 305.) — In this method, 
all the muscles are divided circularly 
down to the bone at one level, which 
is that of the reflected cuff of skin — cal- 
culating to come down upon the bone 
sufficiently far below the saw-line to 
form a musculo-periosteal covering (Fig. w n 

„ r o \ o pjg -2 8o. — Division of Muscles in Oval 

2 7"y- Method of Amputation. 




284 AMPUTATIONS. 

In the Modified Circular Amputation. — (For description, see page 
306.) — After the flaps of skin and fascia have been retracted, the more super- 
ficial muscles are divided on a level with the retracted flaps — this layer of 
muscle tissue is retracted — and the deeper layer is divided upon a level with 
the retracted superficial layer — calculating to come down upon the bone far 
enough below the saw-line to allow for a musculo-periosteal covering (Fig. 279). 
The division of muscles being, in other words, just as in the ordinary circular 
amputation. This is the better way of dividing the muscles in the modified 
circular operation. Where, in the modified circular amputation, the muscles 
are all divided at one level (that of the retracted flaps), the muscles are di- 
vided as in the circular amputation a la manchette. 

In the Oval Method of Amputating. — (For description, see page 307.) 
-After having made the oval incision through skin and fascia, the muscles 
are divided directly to the bone — the knife entering the muscle tissue upon 
the line of the retracted skin and fascia. Along the queue, or vertical portion 
of the oval, which begins at, or just above, the saw-line, or disarticulation- 
line, the two lines of incision will coincide — parting below to follow the 
outlines of the oval — and meeting at the mid-point behind (Fig. 280). 

In the Racket Method of Amputating. — (For description, see page 
308). — The principle here is the same as in the oval method. 

DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 

In Amputating by Single Flap of Skin and Muscle. — (For description, 
see page 309.) — The skin-and-fascia flap having been outlined and incised, 
the muscles are cut, preferably from without inward (or may be cut from 
within outward, by transfixion), beveling inward, on a line with the retracted 
skin-and-fascia flap — the incision coming down upon the bone sufficiently 
far below the saw-line to provide for a musculo-periosteal covering (Fig. 281). 

In Amputating by a Single Skin-flap. — (For description, see page 
311). — Having retracted skin-and-fascia flap, the muscles are divided cir- 
cularly at the saw-line, or disarticulation-line. 

In Amputating by Equal Flaps of Skin and Muscle. — (For description, 
see page 311.) —Same as by single flap of skin and muscle (Fig. 282). 

In Amputating by Equal Flaps of Skin. — (For description, see page 
311.) — Same as by single skin flap. 

In Amputating by Unequal Flaps of Skin and Muscle. — (For de- 
scription, see page 313.) — Same as by single flap of skin and muscle. 

In Amputating by Unequal Flaps of Skin. — (For description, see 
page 314.) — Same as by single flap of skin. 

In Amputating by the Elliptical Method. — (For description, see page 
315.) — As this may be considered a variety of single flap amputation (of 
either skin alone, or of skin and muscle combined), the manner of dealing 
with the muscle is here the same as in that operation. 

In Amputating by Teale's Method of Unequal Rectangular Flaps 
of Skin and Muscle. — (For description, see page 314.) — Upon the line 
of the retracted skin and fascia, the muscles are cut through the periosteum 
along the two vertical lines. The muscles are then cut through the periosteum 
transversely along the free margin of the retracted skin and fascia representing 
the end of the longer flap — all of the soft parts are then dissected up above 
the lower limit of the shorter flap, when the muscles opposite its lower limit 
are transversely divided through periosteum to bone. 

Method of Cutting Flaps from Without Inward. — In this method 
the flaps are cut by dissection, as it is sometimes called. The incision out- 



DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 285 



lining the flap having been made through skin and fascia, the surgeon, standing 
to the outer side of right limbs and inner side of left limbs, and grasping the 
limbs between saw-line and trunk, proceeds to cut the muscle portion of 
the flap. A scalpel is made to cut the muscles along the line of retracted 
skin-and-fascia flap, the point 
of the knife entering the 
muscles at the upper limit of 
one of the limbs of the skin- 
and-fascia flaps — follows this 
margin vertically downward, 
passing deeply through the 
muscles — as the free border 
is approached, the knife is 
given a direction obliquely 
inward, so as to broadly and 
thickly bevel the muscles 
here, leaving them thinnest 
(though not thin) along this 
aspect of the flap — continu- 
ing the beveling process 
across the entire transverse 
width of the free end of the 
flap and well around its 
bluntly rounded corner — 
thence the knife passes ver- 
tically up the opposite limb 
of the flap, sinking deeply 
into the muscles, though the 
bone need not be fully 
reached in the vertical cuts at 
the first stroke (Fig. 283). 
As in cutting skin-flaps, the 
entire incision need not be 
made at one stroke of the 
knife — but is better made 
in two strokes from above 
downward. The surgeon 
now grasps the partly cut 
flap with the fingers of his 
left hand, and, while draw- 
ing it away from the bone, proceeds to fashion the rest of it along the same 
lines upon which it was begun, beveling it toward the bone by successive cuts 
of the knife — planning that the base of the flap will contain the full thickness 
of the soft parts covering the bone — and calculating that the knife will come 
down upon the bone (or bones) far enough below the saw-line (or disarticula- 
tion-line) to provide a musculo-periosteal (or capsulo-periosteal) covering. 
Where two flaps are cut, the second is cut in the same general manner. Care 
should be taken that the muscles are thickly and bluntly beveled, else a thin, 
ill-nourished ending to the flap is apt to be left. No attempt is made to 
bevel the upper part of the sides of the flap (the vertical portions) — the beveling 
beginning only just above the rounded corners. By cutting on a line with 
the retracted skin, ample covering of the muscle-portion of the flap by the 
skin-and-fascia portion is provided (Fig. 282). 

Method of Cutting Flaps from Within Outward. — In this method 




Fig. 281.— Division of Muscles in Amputation by Single 
Flap Method. 



286 



AMPUTATIONS. 



the flaps are cut by transfixion. The skin and fascia should always be cut 
first and from without inward, as the first step of every flap (as well as of 
every other kind of) amputation — no matter what the method of doing the 




Fig. 282.— Division of Muscles in Amputation by Double Flap Method. 

other steps of the operation. If this be not done, the muscles and skin will 
necessarily be cut upon the same, or nearly the same, level — with the inevitable 
result that there will be a deficiency of skin to cover the muscles, owing to 
the greater retraction of the former. Having, therefore, cut the skin and 
fascia flap from without, the surgeon proceeds to cut the muscles by trans- 
fixion. A long knife is taken, having a length equal to at least one-and-a-half 
diameters of the limb at the site in question. Marking the saw-line with 




Fig. 283.— Method of Raising Flaps of Skin and Muscle by Cutting from Without 

Inward. 

the thumb of the left hand, the point of the long knife (whose sides look 
upward and downward and whose edge points toward the extremity to be 
removed) is entered directly in the center of the lateral aspect of the limb 
(where the flaps are to be taken from the anterior and posterior aspects of 
the limb) and opposite the saw-line. The knife-point should be so placed 
and pointed as to avoid important vessels. The knife is then carefully 
pushed directly forward, until its point strikes the center of the lateral aspect 
of the bone (or, if two bones, of that one nearer the operator) — the handle is 
then lowered while the forward progress of the knife continues, so that its 
point is made to hug the bone closely until its upper margin is reached — 
the handle is then raised so as to cause the point to sink and follow, as nearly 
as possible, the surface of the bone (or bones) on the opposite side (which, 



DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 287 

naturally, can be less closely followed than the nearer quadrant of the bone's 
circumference). When the knife's point is felt to have reached a point on 
the far side of the limb corresponding with the center of the bone, the handle 
is then lowered to a horizontal position and the knife thrust on forward until 
it protrudes through the skin on the far side of the limb. The surgeon stops 
here a moment to calculate the line along which the cutting-edge of the knife 
is to emerge — the guide to which being the line of the retracted skin flap. 
With a slow back-and-forth sawing movement, the knife is made to cut 
its way forward — hugging the bone (or bones) closely throughout the greater 
portion of its way — until near the free end of the flap, when it is made to 
round its way out in such a manner as to cut a thickly beveled edge of muscle on 




Fig. 284.T-METHOD of Raising Flaps of Skin and Muscle by Cutting from Within 
Outward (by Transfixion) — cutting upon the line of retracted skin and fascia, which have been 
previously divided. 

a line with the retracted free edge of skin (Fig. 284). In cutting a second flap 
from the opposite aspect of the limb, the first flap is retracted out of the way — 
the knife then passes over the cut surface of the muscle along exactly the 
same course as in beginning the transfixion of the first flap — until its point 
strikes the center of the lateral aspect nearer the surgeon (at exactly the same 
point as in the first manoeuvre). The handle is now raised, to cause the point 
to follow down the lower quarter of the circumference of bone nearer the 
operator — when its lower margin is reached, the handle of the knife is lowered 
and the knife pushed forward, until the inferior surface of the bone (or bones) 
is passed. The handle is now still further lowered and the knife pushed 
forward, so as to cause the point to follow the further inferior quarter of the 
bone and emerge opposite the center of its lateral aspect. But as this manoeuvre 
is difficult to accomplish, the surgeon generally aids the knife with his left 
hand, by partly guiding it and partly depressing the remaining soft parts on 
far side below the point of the knife so that its edge escapes them. Then 
with a similar back-and-forth movement, at first hugging the bone, the knife 
is made to cut its way out on a line with the retracted skin-flap. In order to 
avoid cutting the muscle-flaps too narrow and too thin, it is necessary to hug 
the bone (or bones) until about three-fourths of the flap is cut and then 
abruptly round out to the line of the retracted skin-flap. Great care is also 
necessary to avoid piercing the main vessels in making the transfixion — 
and to avoid splitting them (whether at first transfixed or not) in cutting 



288 AMPUTATIONS. 

forward to form the flap. Therefore, it is sometimes necessary, when forming 
flaps by transfixion, to so plan them that they will not be precisely antero- 
posterior, or lateral — but will be so formed as to be least likely to contain 
split vessels. Considerable tissue at the base of the Hap often escapes division 
in cutting by transfixion and has to be cut subsequently. The method of 
transfixion may be varied by not passing the knife so closely to the bone- 
that is, by transfixing the more superficial muscles only, retracting these, 
and then cutting the deeper muscles circularly at the saw-line. A further 
modification of the transfixion method consists in cutting through skin-and- 
fascia flap from without — then transfixing the apex of the muscle-flap — 
and dissecting up the remaining soft parts. 

Comparison of Methods of Cutting Flaps. — (a) The method of cutting 
from without inward enables a flap to be cut with greater precision — makes 
the wounding and splitting of the main vessels unlikely — and provides for a 
more accurate calculation of covering for the stump, especially as to the 
relation between the amount of skin and muscle covering. It is the method 
to be chosen in the great majority of cases, (b) The method of cutting flaps 
from within outward (transfixion) is a convenient method in very large 
limbs, and in some special amputations, and where speed is necessary. Flaps 
thus cut are apt to have their arteries injured — are apt to be too thinly beveled 
at their free ends — are apt to be too narrow throughout, and too pointed 
at their ends — and, generally, less judgment can be exercised in their fashion- 
ing. Even in the larger limbs a flap can be more satisfactorily cut from 
without inward than by transfixion. Even where transfixion is used, how- 
ever, the skin and fascia should invariably be cut from without — and the 
knife should come out on a line with this retracted skin. 

FREEING AND RETRACTING OF MUSCLES. 

In Ordinary Circular Method. — After the division of the more super- 
ficial muscles by the circular sweep of the knife, it may be found that here 
and there these muscles are not divided to an equal depth. Such unequal 
division, wherever found, is completed by a few strokes of the edge of a 
small knife. This layer of muscles is then retracted upward until the level 
is reached for the circular division of the deeper muscles. 

In Circular Amputation a la Manchette. — Here the muscles are 
divided directly to the bone, on the line of the reflected cuff, and no special 
freeing or retraction of the muscles is done, until ready to make the musculo- 
periosteal covering. 

In Modified Circular Amputation. — The muscles are here freed and 
retracted as in the ordinary circular amputation. 

In Oval Method of Amputation.— Here the muscles are divided on the 
line of the oval — no freeing or retraction being necessary until ready to make 
the musculo-periosteal flap. 

In Racket Method of Amputation. — Same as in the oval method. 

In Single, or Equal, or Unequal Flaps of Skin and Muscle. — (A) 
When Cut from Without; — The fingers of the left hand raise the flap away 
from the bone, while the surgeon cuts the vertical limbs of the flap to the 
bone, and gradually bevels the terminal portion of the flap obliquely upward 
tow T ard the bone. (B) When Cut from Within by Transfixion; — No freeing 
or retraction is necessary, until ready to make the musculo-periosteal covering. 
(The fingers of the left hand may grasp up the soft parts of the limb and 
lift them away from the bone as the knife cuts its way out.) 

In Single, or Equal, or Unequal Flaps of Skin.— The muscles are 



MAKING MUSCULO-PERIOSTEAL COVERING. 289 

here divided on one level — no freeing or retraction being necessary, until 
ready to make the musculo-periosteal covering. 

In Elliptical Method. — The muscles are handled as in an amputation 
by a single flap of skin and muscles. 

In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). 
—The muscles are here handled as in amputation by unequal flaps of skin 
and muscle. 

MAKING MUSCULO-PERIOSTEAL, OR PERIOSTEO-CAPSULAR, COVER- 
ING FOR END OF BONE. 

Description. — A covering should be provided for the end of the ampu- 
tated or disarticulated bone, or bones, which will consist of periosteum and 
overlying muscle, raised as a single musculo-periosteal or periosteo-capsular 
flap or covering. Care should be exercised in raising this covering, that 
muscle is not first raised from periosteum and periosteum from bone, but 
that muscle and periosteum should be raised in one adherent layer. Peri- 
osteum is absent over cartilaginous surfaces, hence a pure musculo-periosteal 
covering is not to be gotten in a disarticulation — but as much of the capsule 
of the joint, which is practically a continuation of the periosteum, should 
be preserved as possible, and treated in the same way as the periosteum, 
that the articular end of the proximal bone may be covered. The distinct 
advantages of a musculo-periosteal covering for the end of the bone are the 
following; — (1) The muscles being adherent to the periosteum, when a 
covering of the latter is stitched over the bone, a thicker and more fixed 
covering to the end of the bone is secured than could be otherwise attained: 
— (2) The end of the bone being covered by periosteum, adhesion of the 
soft parts to the end of the bone is far less likely, the parts covering the bone 
generally remaining freely movable, and are, therefore, both better nourished 
and are less likely to become painful; — (3) The medullary cavity of the bone 
being shut off by the musculo-periosteal covering, is much less apt to become 
involved in any septic process which may arise in the stump. The only 
objections which can be raised to a musculo-periosteal covering are the 
time and trouble involved — which should not be allowed to weigh against 
the practical advantages — nor should the possible formation of osteophytes and 
proliferation of bone from the turned-over periosteum be seriously regarded. 

Manner of Providing Musculo-periosteal Covering in all Forms 
of Circular Amputation, and in all Double-flap Amputations Cut from 
Without Inward. — The surgeon should plan to have his knife pass through 
the deep layer of muscles surrounding the bone in such a way as to come 
down through these muscles and upon the periosteum without separating 
muscles from periosteum (which would also detach the vascular supply 
of the periosteum), and at such a level on the bone below the saw-line as to 
equal a full half-diameter of the bone at the saw-line. In circular amputa- 
tions this final cut will pass transversely through the muscles, — in flap ampu- 
tations, obliquely through, in the process of beveling. As soon as the peri- 
osteum is reached in this final incision, all the soft parts are carefully retracted 
around the whole circumference of bone at this level, especial care being 
taken not to use force in the retraction, thereby separating muscle from 
periosteum by dragging the former off of the latter. A circular incision 
is now made through the periosteum around the entire circumference of 
bone, at the level of the lightly retracted muscles — cutting the periosteum 
with especial firmness where closely bound to the lineae aspera?. The peri- 

!9 



290 



AMPUTATIONS. 



osteum is then detached back to the line of the future saw-cut, by means of 
a periosteal elevator — care being exercised not to push the muscles off the 
periosteum, but to push the periosteum back from the bone with the muscles 
attached (Fig. 285). 

In Flap Amputations by Transfixion. — The knife should be entered just 
far enough below the saw-line to equal a full half-diameter, or more, of bone at 
the sawdine. When the flaps are cut, the periosteum is divided circularly 
at this level — and then the periosteum and muscles are detached back to 




Fig. 285.— Raising a Musculo-periosteal Covering — in the circular method of amputation. 



the sawdine — or the periosteum may be raised as two small flaps, their 
incision beginning at the sawdine (Fig. 286). 

In Oval and Racket Modifications of the Circular Amputation. — 
The freeing back of the muscles should be stopped at a level equal to a full 
half-diameter, or more, of the bone below the saw-line — the periosteum is 
here circularly divided — and the periosteum and muscles detached thence 
back to the saw-line. 

In Single-flap Amputations of Skin and Muscle. — The knife comes 
down upon the bone one full diameter, or more, of bone below the saw-line. As 
the two vertical limbs of the flap have been cut down to the periosteum in the 
earlier part of the operation, a musculo-periosteal flap is now marked out, 
having a base equal to half the circumference of the bone at the saw-line 
and a length equal to one full diameter, or more, of the bone at the saw-line. 
The periosteum and muscles are now detached back to the line of bone-section 
— all the hitherto undisturbed parts on the opposite side of the limb are 
now divided transversely to the bone — and the bone sawed. 

In Flap Amputations of Skin Only. — As the muscles are here divided 
circularly, the musculo-periosteal flap is provided for just as in the ordinary 
circular amputation. 

In the Elliptical Modification of the Single-flap Method. — The 
musculo-periosteal covering is handled as in the single flap of skin and muscle. 

In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). 
— The musculo-periosteal covering is secured as in amputation by unequal 
flaps of skin and muscle. 

In Amputating Limbs with Two Bones. — The musculo-periosteal 
covering for the larger bone is provided as described in the single-bone limbs. 



MAKING MUSCULO-PERIOSTEAL COVERING. 291 

The musculo-periosteal covering for the smaller bone is provided in the 
same manner, but will be cut at a higher level (as it is circularly divided, or 
a flap is cut, which will be equivalent to the smaller diameter of the smaller 
bone). Where the bones are of the same size, the periosteum is divided 
at the same level in each case — which may also be done when the bones 
are of unequal size, the redundancy of periosteum in the case of the smaller 
bone being subsequently removed with scissors, if necessary. 




Fig. 286.— Raising a Musculo-periosteal Covering— in the flap method of amputating. 

Note. — The final treatment of the periosteal covering cannot be carried 
out until after the division of bone. 

Comment. — (1) It will be seen that in circular amputations and in ampu- 
tations by double flaps, the musculo-periosteal covering is furnished from 
the entire circumference of the bone — while in amputations by single flaps, 
a single flap of musculo-periosteal tissue is raised, the width of which is 
equal to a half-circumference of bone and a length equal to a diameter of 
bone. (2) As there is comparatively little retraction of fibrous periosteal 
tissue, the chief retraction taking place in the attached and overlying muscles, 
a length for the musculo-periosteal covering of one full diameter of the bone 
(each side of the bone hereby furnishing one-half diameter) will, therefore, 
cover the end of the bone, but none too fully — so that this measurement 
should be made very full. (3) Where it is difficult to detach the musculo- 
periosteal covering backward after simply a circular division of the periosteum, 
two vertical incisions may be made upon the lateral aspects of the bone, 
from the site of the saw-line to join the circular cut — which will make the 
detachment easier. These vertical incisions may, indeed, be made in aD 
cases. Even where the vertical incisions are not made in detaching the 
periosteum, they may be subsequently made before adjusting the periosteal 
flaps or covering. In the pure flap amputations the muscles have already 
been divided to the periosteum, so that the knife easily makes the two vertical 
incisions in the periosteum. In the circular amputation where it is necessary 
to add the vertical cuts before sawing the bone (that is, in order to reach the 
saw line), the point of the knife may be pushed into the transversely divided 
muscles, in the long axis of the limb, up to the saw-line (which will lie only 
a half-diameter of the bone above) and cut downward thence to join the 
circular cut. (4) In the case of the two-bone limbs, the interosseous mem- 
brane is also freed back in the act of detaching the periosteum. (5) Some 
hold that the periosteal covering is without value in the adult and actually 
harmful in the young, owing to the possibility of reproduction of bone render- 



292 



AMPUTATIONS. 



ing the stump conical. The former is an error of observation. The latter 
must be very rare, the epiphysis being responsible for the chief increase of 
length of bone. 




Fig. 287.— Retraction of Soft Parts Preparatory to Sawing of Bone— in the case of a 
single-bone limb. A single-tail retractor is shown above. 



RETRACTION OF SOFT PARTS PREPARATORY TO SAWING THE 

BONE. 

All the soft parts overlying the bone having now been divided, from skin 
to periosteum, these soft parts are to be retracted above and out of 

the way of the saw- 
line, which should be 
seen to be clear in its 
entire circumference 
before making the 
bone-section. 

In Si ngle-bone 
Limbs. — A double- 
tailed linen retractor 
is generally used to 
hold the soft parts 
back — the two tails 
of the retractor pass- 
ing around the bone, 
thus supporting the 
soft parts and drawing 
them upward and out 
of the way (Fig. 287). 
In Double -bone 
Limbs. — A three-tailed linen retractor is usually used — the central tail pass- 
ing between the bones — the outer of the other two tails on the outer side of 
the outer bone, and the inner on the inner side of the inner bone (Fig. 288). 
Comment.- — The parts may also be retracted by the hands, or by various 
forms of metallic or other retractors, such as Cooper's retractors (Fig. 289). 

SAWING THE BONE, OR BONES. 

General Considerations. — The surgeon, standing to the outer side 
of right limbs and to the inner side of left limbs, grasps the limb firmly with 




Fig. 288.— Retraction of Soft Parts Preparatory to 
Sawing of Bone — in the case of a double-bone limb. A double- 
tail retractor is shown above. 



SAWING THE BONE, OR BONES. 



2 93 



his left hand just above the saw-line. An assistant supports the distal portion 
of the limb, holding it out over the side of the table, and on an exact line 
with the level at which the limb leaves the trunk, in the case of the arm and 
thigh; and on a level with the surgeon's left hand in the case of the forearm 




Fig. 28q. — Cooper's Metallic Amputation Retractors. 

and leg. If he elevates it above the common level, he will bind the surgeon's 
saw throughout the entire transverse section (because the parallel walls of 
the section will tend to approximate), — and if he depresses it below the common 
level, while he makes it easier for the surgeon to saw, he is apt to splinter 
the bone just before the section is completed (because the parallel walls of 
the section will tend to diverge). 




Fig. 290.— Manner of Sawing the Bone — in the case of a single-bone limb. 



In Single-bone Limbs. — The surgeon places the edge of his thumb- 
nail down upon the bone immediately above the saw-line, as a guide to the 
saw, temporarily loosening but not entirely relaxing his steadying hold with 
the other fingers and palm upon the limb. Holding an ordinary amputating 
saw in his right hand, he deliberately places its heel against his thumb and 
knuckles, and directly over the saw-line — and, with a fairly slow but firm 
and steadv movement, he draws the saw backward from heel to point, thus 
grooving the bone transversely. If this groove be not distinct or deep enough, 



294 



AMPUTATIONS. 



the first movement (from heel to point) may be repeated. The surgeon 
now resumes his steadying grasp of the limb with his left hand and proceeds 
to saw the bone by slow, even, steady, back-and-forth strokes of the saw, 
traveling the entire length of the saw-blade at each stroke — and avoiding 
uneven and too rapid sawing, the latter sometimes generating a harmful 
degree of heat. It is during the section of the latter part of the bone that 
the assistant is most careful in his manner of holding the limb and the surgeon 
in his use of the saw. Toward the last the strokes of the saw should be 
slower, shorter, and lighter, and the limb so balanced that there will be no 
cross-strain anywhere throughout its length — and thus are the chances of 
splintering minimized. If indicated, the larger saw may be removed toward 
the last and the section be completed with a lighter, finer saw, but this is 
ordinarily unnecessary. As the bones of both single-bone limbs are nearly 
circular, no beveling of the edges is needed (Fig. 290) . 

In Double-bone Limbs. — The general manipulative method is here 
the same as in the single-bone limbs. The saw first engages the heavier 
bone, and, having passed partly through this, is dropped upon the lighter 
or more movable bone — the section of which latter bone should be first com- 
pleted, the saw all the while cutting the heavier bone also, which it finally 
completes alone. Where both bones are of the same size (as the middle 
of the forearm), the saw grooves the one nearer the operator and is then 

dropped upon the farther one. 
Where a bone presents a promi- 
nent ridge, almost or quite sub- 
cutaneous (as the anterior border 
of the tibia), this would become 
an angular projection after sec- 
tion of the bone and would be 
apt to become a prominent point 
of pressure. To avoid this, this 
edge of bone should be beveled — 
which is best done by making an 
oblique saw-cut from above down- 
ward, beginning about 1.3 cm. (£ 
inch) above the saw-line and pass- 
ing obliquely into the bone at such 
an angle as to be about 6 or 8 mm. (j or ^ inch) below the level of the bone by the 
time it has reached the saw-line. Having made this 1.3 cm. (^ inch) oblique 
saw-cut into the bone, the saw is then withdrawn and is made to traverse 
the bone transversely along the line of bone-section in the ordinary manner. 
When the saw, traveling transversely, reaches the short oblique section, 
the small triangle of bone will drop out — and when the section is completed, 
the prominent edge of the bone will be found beveled (Fig. 291). 

Comment. — In the very young, and especially in amputating those bones 
which grow chiefly from an upper epiphysis, it is well to saw the bone as high 
as possible — as subsequent growth from such bones may require reamputation. 




Fig. 291. — Manner of Sawing the Bones — 
in the case of a double-bone limb. The method of 
beveling a prominent margin of bone is also here 
shown. 



REMOVING SPLINTERED BONE. 

If, in the final saw-section, whether by splintering or a transverse snapping 
of the frail bridge of bone, a fragment of bone is left projecting from the 
stump, or any other projecting irregularity should appear upon the trans- 
versely divided bone, this should be removed down to a level with the face 
of the bone. This is accomplished by grasping the spicula of bone with 



LIGATIXG ARTERIES AXD VEINS. 295 

bone-holding forceps (such as the lion-jaw type) and steadying it, while the 
surgeon removes the spicula with a small, fine saw (Fig. 292). 

Comment. — (1) Bony projections are often crudely crushed off with 
bone-cutting forceps — this is quickly done and is a temptation — but is not 
to be recommended, as necrosis of the margin of the bone is more apt to 
follow crushing than sawing. (2) The splinter of bone may be upon the 




292.-MANXER of Removing a Piece of Splintered Bone. 



portion of bone removed — there will then be a corresponding depression, 
with probably a tearing of periosteum and muscles, upon the bone in the 
stump — which may require to be evened off. 

LIGATING ARTERIES AND VEINS. 

As soon as the bone has been sawed, all the chief arteries and the larger 
veins should be tied. The arteries are tied in the order of their importance 
and are sought in their known positions. They have frequently retracted 
somewhat, so as to be out of sight, and are to be traced by their known rela- 
tions. The stump should be held in a good position and light — and, if 
necessary, dried of blood. The cut ends of the arteries are caught by catch- 
forceps and drawn out of their beds by the surgeon — while an assistant 
ligates the larger vessels with chromic catgut, tying them with a surgeon's 
knot. The larger arteries may be tied with the stay-knot of Edmunds and 
Ballance (page 24). All the vessels should be clamped before any are tied. 
The larger arteries should be drawn out of their sheath before being tied. 
The smaller arteries with their sheaths may be included in the ligature. 
Arteries which are caught with difficulty with catch-forceps may be taken 
up with a tenaculum. Very small vessels may be compressed or twisted 
without ligaturing. The chief veins should be tied — as well as any others 
which are seen gaping. All vessels should be tied as long as possible — and 
should be disturbed in their sheath as little as possible. Arteries bleeding 
from their osseous canals in the end of the bone cannot be tied, but may be 
controlled by plugging the vascular canal with a piece of catgut, a piece of 
sterilized wood, or with Horsley's antiseptic wax, or Halsted's gut-wool — 



296 



AMPUTATIONS. 



or a limited portion of the canal may be crushed in upon itself. After all 
known vessels are tied, the Esmarch, or other constrictor, should be relaxed 
and all hitherto untied vessels which now bleed are to be ligated (Fig. 293, A, 
B, and C). 

Comment. — (1) See that the first knot (friction-knot) does not loosen 
before the second knot (surgeon's knot) is complete — and that the knot is 
far enough from the end of the vessel not to slip off. (2) Where hemorrhage 




Fig. 293.— Stump after Amputating through Lower Part of Right Leg: — A, Ligation of 
anterior tibial artery; B, Clamping of posterior tibial artery; C, Plugging vascular canal of bone 
with piece of catgut ; D, Cutting off tag of peroneus longus ; E, Cutting anterior tibial nerve short. 



is apprehended, vessels may be taken up immediately after dividing the 
soft parts, and before even severing the bone. Instead of taking up and 
tying the vessels seriatim, they may be immediately clamped, one after another, 
and, if not tied at once, the catch-forceps may be retracted with the flaps, 
or with the circular division of soft parts, and the bone sawed, after which the 
vessels are tied — relaxing the original hold where vessel and sheath are in- 
cluded and taking up vessel alone. (3) Obstinate oozing may generally be 



SUTURING OF MUSCULO-PERIOSTEAL COVERING. 297 

controlled by ligating en masse — or by douching with hot saline solution, or 
by pressure. This is the form of hemorrhage which is more apt to occur 
after the removal of the constrictor. 



TREATMENT OF NERVES, TENDONS, AND TAGS OF MUSCLE, FASCIA, 

AND SKIN. 

(1) All nerves should be cut as short as possible, to avoid entanglement 
and pressure in the process of cicatrization — to accomplish which they should 
be caught bv forceps and drawn well out and then cut with scissors and 
allowed to retract out of sight. Where the flap method has been done and 
it is likely that an important nerve may be subjected to pressure when the 
flaps are bent and sutured over the end of the bone, the nerve should be dis- 
sected out. This is especially the case in the method of single-flap ampu- 
tation. Nerve ends are apt to become bulbous in any event, but will not 
be troublesome unless subjected to pressure. (2) All tendons should be 
caught with forceps, steadied, and cut short under slight tension. They are 
difficult to cut unless steadily held and slightly stretched — when they may 
be cut with scissors or a very sharp knife. Tendon-ends possess low vitality, 
are apt to slough, fulfil no useful purpose in the stump, and make but poor 
covering. (3) All tags and irregularities of muscle, fascia, and skin should 
be evenlv trimmed, so as to conform with the general contour. (Fig. 293, 
E and D.) 

TRIMMING OF FLAPS. 

It is undesirable, and somewhat unsurgical, to make a miscalculation in 
the length or contour of a flap, which will require any subsequent trimming 
■ — but where a flap is distinctly too long, or too large, or misshapen, it is 
better to do the trimming necessary to make a good fit than to suture it in 
place as it is. It is held in the left hand, or caught with forceps, and trimmed 
as one would trim a piece of paper. A flap may be trimmed as a whole — or 
some individual tissue composing it may be trimmed. 

RE-AMPUTATION FOR IMPROPERLY MADE FLAPS. 
It is even more unsurgical, and much more difficult to rectify, to find 
that so little allowance of covering has been made that the end of the bone 
either cannot be covered at all, or cannot be covered without a degree of 
tension calculated to endanger the flaps. In such a case all that one can 
do is to amputate at a higher level. If only a slight deficiency of covering 
exist, the end of the bone may be freed of its soft parts by retraction and 
made to project and then be removed by the saw. Where the deficiency is 
greater, from one to several inches of the soft parts may also have to be re- 
moved, as well as the bone. In such a case one proceeds very much as in 
the original operation, modified by the needs. 



ADJUSTMENT AND SUTURING OF MUSCULO-PERIOSTEAL OR 
PERIOSTEO-CAPSULAR COVERING. 

The first step in the closure of the stump-tissues is the adjustment of the 
musculo-periosteal covering. It will be remembered that in all circular 
amputations, and in all double-flap amputations of skin and muscle, the 



298 AMPUTATIONS. 

musculo-periosteal covering was made by a circular division of the periosteum 
around the bone one-half of a full diameter of the bone below the saw-line 
(thus furnishing a full diameter), and that the periosteum, with adherent 
muscles, was then detached in one layer up to the saw-line. Therefore, 
after the bone is sawed and the soft parts drop down around its cut end, 
the musculo-periosteal covering will form a hollow cylinder projecting from 
the lower surface of the transversely sawed bone — the periosteum hanging 
down around the bone for a depth, approximately, of a half diameter of the 
bone, the muscles being adherent to its outer side. This cuff of musculo- 
periosteal covering may be converted into two small flaps by cutting along 
its lateral aspects with straight-pointed scissors, from its lower free margins 
up to the bone. The corners of these little flaps may then be slightly rounded, 
though this is not necessary. These two flaps are then dropped over the 
end of the bone and their edges are sutured together with catgut, the sutures 
passing through periosteum and muscles. While the above method makes 
a neater fit, it is not really necessary that the musculo-periosteal covering 

should be slit up at all on the 
sides — it suffices simply to ap- 
proximate the edges over the 
bone by a suture running either 
antero-posteriorly or trans- 
versely. Where the musculo- 
periosteal covering has been 
raised in the form of a single 
flap (as in the amputation by a 
single flap), this single flap of 
musculo-periosteal covering is 
dropped over the end of the 
bone and its margins sutured 
to the cut margins of the peri- 
osteum around the rest of the 
ering. circumference of bone, including 

the muscle overlying the perios- 
teum. Where the bone-section is very small, it is often difficult to adopt 
any definite plan of making and suturing a musculo-periosteal flap, the per- 
iosteum being torn in shreds in the process of detachment. In such cases 
the mass of musculo-periosteal tissue is simply gathered together and sutured 
over the end of the bone. (Figs. 294 and 302.) 

QUILTING OF MUSCLES. 

The muscle tissue which enters into the covering of the bone should, 
where possible, be approximated and sutured into apposition by buried 
chromic gut sutures, placed in one or more tiers, by means of either buried 
simple sutures, or buried quilt- or mattress-sutures. Thus the cut aspects 
of the muscles are brought into contact, — less tendency for them to retract 
away from the end of the bone occurs, — in the process of cicatrization they 
become incorporated in the general pad of covering which forms the stump 
(even though the muscle tissue itself may be subsequently replaced by fibrous 
tissue), — there is less chance of adhesions forming between bone and skin, — 
and, altogether, a fuller, softer, better-formed pad of covering is provided. 
These advantages more than counterbalance the only two disadvantages — 
namely, of time and trouble involved. By the process of quilting, muscles 




QUILTING OF MUSCLES. 



299 




Fig.295.-Qu11.TiNG of Muscles in Circular 
Method of Amputation: — First tier of sutures 
has been placed — and is being buried by the second 
tier. 



are brought and held in contact until united, which, in the ordinary method 
of simply dropping muscles over the ends of the bones and depending upon 
the single line of marginal skin-sutures to approximate, either could not be 
made to come into contact even temporarily, or, if so, would generally retract 
apart before union. 

In Circular (Infundibuliform Variety), Modified Circular, Oval, 
and Racket Methods. — After su- 
turing the musculo-periosteal cover- 
ing the muscle surfaces are brought 
into contact immediately over the 
musculo-periosteally covered end of 
bone. The approximation of mus- 
cle tissue over the bone may be 
made in the way in which the mus- 
cles most naturally fall. Other 
things being equal, the approxima- 
tion should be made so as to cause 
the suture line to be parallel with 
the future suture line of the integu- 
mentary coverings. The first tier 
of sutures is placed nearer the bone, 
entering and leaving the muscle tis- 
sue at such a distance from the 
bone as to secure an easy ap- 
proximation of the muscle substance 

over the end of bone. This first row of sutures, which, if of the simple 
form, may be either interrupted or continuous, will conceal the end of the 
bone. A second tier, especially in heavily muscled limbs, or in thin 

limbs with large muscle 
flaps, should be applied 
—being inserted nearer 
the edge of the muscle 
tissue than the first — 
and, when tied, will hide 
the first row (Fig. 295). 
In Circular 
Method a La Man- 
chette. — As the mus- 
cles are here all divided 
on one level, and that 
'\ level is that of the re- 

tracted skin, skin and 
fascia alone cover the 
end of the bone, and 
no approximation and 
quilting of the muscles 
are possible. 
In All Double-flap Amputations of Skin and Muscle. — The muscles 
are quilted in the same manner as in the ordinary circular (infundibuli- 
form), the process of muscle-quilting being easier in the double-flap 
method than in the ordinary circular, as the muscles are adherent to the 
flaps on either side and are more readily held in approximation while being 
quilted (Fig. 296). 




Fig. 296.— Quilting of Muscles in Flap Method of Ampu- 
tation : — First tier of buried sutures has been placed and tied — 
and second tier is being placed. 



300 AMPUTATIONS. 

In All Double Flaps of Skin. — No quilting of muscles is here possible 
— as the muscles are transversely divided on a level with the retracted skin- 
flaps. 

In All Single Flaps of Skin and Muscle, Including the Elliptical 
Method. — As the muscles are here divided obliquely on the side of the flap, 
and transversely on the opposite side, the quilting of muscles is not done 
as in the above-described methods (where the lateral aspects of the muscles 
are sutured to lateral aspect, or ends to ends). The lateral aspect of the 
muscles in the present instance, some of which aspect is made up by the 
obliquely beveled muscles, is sutured to the transversely divided muscles 
on the side of the limb opposite to the flap — and the ends of the muscles in 
the flap are sutured to the circumferential margin of the transversely divided 
muscles in the stump. As the base of the flap comes from a full half-cir- 
cumference of the limb, the bent-over flap is only approximated to the opposite 
half of the face of the stump. Where the elliptical method is used in the 
neighborhood of an articulation (that is, in a disarticulation) where only 
tendons pass over and cover the joint, no quilting is possible. It is, therefore, 
applicable only where muscles cover bones, which, in the case of the joints, is 
only at the shoulder and hip. 

DRAINAGE. 

No drainage is necessary in amputating through sound tissue in the 
continuity of a limb. Temporary drainage (for two or three days) may be 
instituted in disarticulating through the larger joints — to provide for the 
escape of the synovial fluid which the remaining synovial surfaces will go 
on secreting for a time. Where drainage is indicated, it is sometimes better 
to make a counter-opening than to attempt to drain through a non-dependent 
suture-line. Drainage may be temporarily used where bleeding in the 
stump-tissues is feared after prolonged use of an Esmarch, or for other reason. 
Drains of rubber-tubing, glass, gauze, or bone-tube may be used. 



SUTURING OF THE STUMP. 

The suturing of the edges of the wound should be done with silk and by 
means of interrupted sutures. Where no great tension is likely to occur, 
silkworm-gut may be used. Catgut is also employed. The parts should 
come together without tension. The interrupted is to be preferred to the 
continuous form of suturing, for the parts may be thereby more accurately 
adjusted — and if it become necessary to open any part of the wound for 
drainage, or other cause, only the few indicated sutures need be cut. 

In Circular Amputations. — It is optional with the operator as to whether 
the soft parts are so approximated as to result in a line of sutures running 
from before backward, or from side to side. The former is to be preferred, 
as the lower end of the suture-line (in the recumbent position of the patient) 
drains the wound by gravity, in case drainage be necessary. Where skin 
and muscle come evenly to the edge of the wound, both are included in the 
sutures. Where skin is longer than muscle, the sutures which close the 
wound pass through skin only — the muscles having been approximated by 
their own buried sutures. 

In Flap Amputations. — Here the direction of the line of sutures will be 
determined by the position of the flaps. Where double flaps are taken 
from the anterior and posterior aspects of a limb, the suture-line will run 



THE EVOLUTION OF AMPUTATION METHODS. 301 

from side to side. Where double flaps are taken from the lateral aspects 
the suture-line will be antero-posterior. Where a single flap is approximated 
to the opposite side of the limb, its margin is sutured to the opposite half- 
circumference. Where the margin of the flaps is composed of skin and 
muscle, both are included in the sutures. Where the skin is longer than the 
muscle, the skin alone is included in the suturing. In all cases the muscle 
surfaces are supposed to have been quilted together prior to the final closure 
of the wound. 

Comment. — (1) Owing to the difficulty of equally dividing out the posi- 
tions for sutures where a large wound is to be brought together, it is well 
to begin by putting in a central suture and then divide each remaining half 
of the space into quarters by two other sutures — then these smaller lengths 
can be sutured with interrupted or continuous suture — the former being 
better, as, in case it be necessary to loosen any suture for suppuration, or 
otherwise, the entire line need not be loosened. (2) If tension upon the 
edges be great, a few tension-sutures mav be used. 



DRESSING OF THE WOUND. 

The wound and stump should be covered with absorbent gauze — the 
entire stump enveloped in absorbent cotton — which should be snugly bandaged 
to the end of the stump and the circumference of the limb. A padded poste- 
rior splint should be incorporated in the outer layers of the dressing, pro- 
jecting beyond the stump slightly — both to support the part; protect it from 
injury; and control, or lessen, the muscular startings which are apt to occur. 
The stump should rest upon an inclined plane, outside of bed-covering. 



REMOVAL OF DRESSINGS. 

If all goes well, the dressings are not removed until about the tenth day 
(or from the tenth to the fourteenth). If a drainage-tube be used, the dress- 
ings are often changed when that is withdrawn — although it is sometimes 
withdrawn at the end of the second or third day — and the dressings not 
removed until the usual time. 



THE METHODS OF AMPUTATION. 
THE EVOLUTION OF AMPUTATION METHODS. 

The methods of amputation have undergone a slow process of evolution 
— which may be briefly stated in the following tabular form (modified from 
Kocher). 

Circular Incision. — The fundamental type of amputation. Of which 
there are two varieties, and from which all other methods of amputation 
may be derived; — (a) Transverse circular incision (Fig. 297, A); (b) Oblique 
circular incision (Fig. 297, B). 

Racket Incision. — Formed by the addition of a longitudinal incision 
to the circular incision, (a) If the longitudinal incision be added to the 
transverse circular incision, the transverse racket incision results (Fig. 297, 
C); (b) If the longitudinal incision be added to the oblique circular incision, 
the oblique racket incision results (Fig. 297, D). Xote — The corners of the 



302 AMPUTATIONS. 

racket incision are now generally rounded off, as in the oval method, the 




Fig.297.— The Evolution of Amputation Methods: — I — A, Transverse circular incision; B, 
Oblique circular incision; C, Transverse racket incision; D, Oblique racket incision. (Modified 
from Kocher.) 

only practical difference between the two, as now usually employed, being 
that the queue is made longer in the racket method. 

Oval Incision. — Formed by the shortening of the queue and the rounding- 




Fig. 298.— The Evolution of Amputation Methods : — II— A, Transverse oval incision ; 
B, Oblique oval incision; C, Equal rectangular flaps; D, Unequal rectangular flaps. (Modified 
from Kocher.) 

off of the angles of the racket incision, (a) If the angles of the transverse 
racket incision be rounded, the transverse oval incision results (Fig. 298, A); 




Fig. 299.— The Evolution of Amputation Methods: — III — A, Equal rounded flaps ; B, Unequal 
rounded flaps. (Modified from Kocher.) 



(b) If the angles of the oblique racket incision be rounded off, the oblique oval 
incision results (Fig. 298, B). 



ORDINARY CIRCULAR AMPUTATION. 303 

Rectangular Flaps. — Formed by adding two longitudinal incisions to the 
circular incision, (a) If the two longitudinal incisions be added to the circular 
incision, equal rectangular flaps result (Fig. 298, C) ; (b) If they be added to 
the oblique circular incision, unequal rectangular flaps result (Fig. 298, D). 

Rounded Flaps. — Formed by rounding the angles of the rectangular 
flaps, (a) If the angles of equal rectangular flaps be rounded, equal rounded 
flaps result (Fig. 299, A) ; (b) If the angles of unequal rectangular flaps be 
rounded, unequal rounded flaps result (Fig. 299, B). 

Elliptical Method. — The position of this method, in the process of evo 
lution, will be described further on (page 315). 



SUMMARY OF AMPUTATION METHODS. 

Fundamental Types. — Circular Method; Flap Method. 

Modern Types. — (a) Circular and its modifications; (b) Flap and its 
modifications; (c) Irregular methods of amputation. 

As to Nature of Covering of Stump. — All methods of amputation 
are either — (a) Skin Coverings — that is, skin and fascia alone cover the 
divided muscles and bone, as in the cuff method of the circular amputation, 
and in the simple skin-flap in the flap method of amputation; — or (b) Skin- 
and-muscle Coverings — where skin, fascia, and muscles, combined and un- 
separated, including the periosteum, cover the end of the bone, as in the 
ordinary (infundibuliform) circular amputation, and in flaps of skin and 
muscle in the flap method of amputation. 



CIRCULAR METHODS OF AMPUTATING. 

(a) Ordinary Circular Method — (amputation circulaire infundibuli- 
forme); — (b) Cuff Method of Circular Amputation — (amputation a la nian- 
chette); — (c) Modified Circular Method of Amputation — (mixed method); — 
(d) Oval (or Lanceolate) Method;— (e) Racket Method. 



ORDINARY CIRCULAR AMPUTATION. 

(AMPUTATION CIRCULAIRE INFUNDIBULIFORME). 

General Description. — The soft parts are divided by a series of circular 
cuts, retraction of the parts taking place between each circular sweep of the 
knife, so that they are cut partly through at different levels — the sawed bone 
forming the apex of the funnel left upon the proximal end of the limb, and 
the skin margin the base — the distal part removed being cone-shaped. 

Technic. — Stand to outer side of right and inner side of left limbs, so 
as to grasp limb between trunk and amputation-site. Determine the saw- 
line. Fix the skin incision at a level below the saw-line equal to \ of ih 
times the diameter of the limb (or three-fourths of that diameter) at the 
saw-line (that is, at 11.5 cm., or 4J inches, below the saw-line, if the diam- 
eter of the limb at the saw-line be 15.3 cm., or 6 inches) (Fig. 300, A). 
Grasp the limb just above the line of the skin incision with the left 
hand and retract the skin upward, aided, if the limb be large, by an 
assistant. With a long knife, make a circular incision, at the skin-incision 
line, through skin and superficial fascia, entirely around the limb. Free 
skin with its superficial fascia from the muscles with their deep fascia, aiding 



3°4 



AMPUTATIONS. 



the separation in the interfascial line by touches with a scalpel, where neces- 
sary. Retract the skin and fascia evenly around the circumference of the 
limb. Divide the more superficial layer of muscles circularly, on a level 
with the retracted skin. Retract this more superficial layer of muscles. 
Divide the remaining deeper muscles circularly on a level with the retracted 
outer layer of muscles — and planning to come down upon the bone, or 
bones, far enough below the saw-line to allow of making a musculo-periosteal 
covering for the bone or bones. Retract the deeper muscles thus cut. Divide 
with a stout knife, the periosteum circularly around the bone, or bones, at a 
distance below the saw-line equal to a good one-half diameter of the bone 




Figs. 300 and 301.— Ordinary (Infundibular) Form of Circular Amputation : — A, Position 
of incision and bone-section ; B, Resulting suture-line. The skin-incision and suture-line here are 
also applicable to the cuff variety of the circular method. 



at the saw-line. Push up the periosteum from the bone with periosteal 
elevator — keeping the muscles adherent to the periosteum. Apply linen 
(or other) retractors to the soft parts and draw them above the saw-line. 
Saw the bone, or bones. If splintering occur, grasp the spicula with forceps 
and remove with finer saw. Allow the soft parts to drop over the end of 
bone, or bones, the sawed ends of which will form the apex of a funnel — 
the bone being covered by periosteum — periosteum by muscle — and muscle 
by fascia and skin (Fig. 302). Tie the vessels — cut the nerves and ten- 
dons short — and remove any tags of connective tissue or skin. Suture 
the musculo-periosteal covering over the end of bone, or bones. Quilt the 



CUFF METHOD OF CIRCULAR AMPUTATION. 



3°5 



muscles together in one or two layers. Suture the skin and fascia antero- 
posterior!}' (Fig. 301, B) — and apply the dressing and supporting splint. 

Resulting Stump. — Evenly covered on all sides by muscle and skin 
— the bone being particularly well protected and on a higher level above the 
surface of the stump than in any other 
form of amputation. The scar is ter- 
minal — antero-posterior, if the wound be 
sutured from before backward, — lateral, 
if sutured from side to side (Fig. 301, B). 

Indications. — In limbs more or less 
evenly surrounded by muscles: — lower 
part of forearm (sometimes), arm, and 
thigh. 

Comment. — (1) Owing to unequal 
skin retraction in some localities (as the 
antero-internal aspect of the arm and 
thigh) the circular incision may have to 
be planned obliquely and only become 
circular after the incision — and may also 
have to be planned lower. (2) A pure 
ordinary circular (infundibuliform) am- 
putation is impossible in a limb of rap- 
idly increasing girth, as it is impossible 
to retract the soft parts. A single lateral 
vertical incision through skin and fascia, 
or double lateral incisions, may become 
necessary in order to free the parts — 
when it ceases to be a typical infundi- 
buliform amputation. 




Fig. 302.— Appearance of the Parts 
Following the Infundibular Form of 
Circular Amputation :— A funnel-shaped 
cavity left proximally, and a cone-shaped 
mass distallv. 



CUFF METHOD OF CIRCULAR AMPUTATION 

(CIRCULAR AMPUTATION A LA MANCHETTE). 

General Description. — A circular division of the skin is made, which 
is turned over and upward upon itself as a cuff — and, upon a level with this 
retracted cuff of skin and fascia, the muscles are divided to the bone, generally 
with one circular sweep of a long knife. 

Technic. — The steps of the operation are similar to those of the ordinary 
circular amputation (page 303) up to the completion of the circular incision 
through the skin and superficial fascia. The skin and subcutaneous tissue 
are then turned back upon themselves as a cuff — the freeing being done 
by means of the fingers of the left hand, aided by touches of a scalpel, until 
evenly retracted all around. On a level with the retracted cuff, the muscles 
are circularly divided down to the bone — the site at which this division takes 
place being such as will allow of ample and easy covering of the transversely 
divided muscle by the skin and fascia — an average calculation being that 
about one-third of the total distance from saw-line to line of skin incision 
should be given to skin and fascia alone. The subsequent steps of the opera- 
tion, including the musculo-periosteal covering for the bone, being the same 
as for the ordinary, or infundibuliform, circular amputation. 

Resulting Stump. — Apt to be more or less irregular in contour and not 
so well padded, owing to the nature of the parts used for covering. The 
scar lies as in the ordinary circular amputation (Fig. 301). 



306 



AMPUTATIONS. 



Indications. — Most frequently used where the soft coverings are more 
tendinous than muscular: — wrist, lower part of forearm, ankle, and lower 
part of leg (in thin subjects). 

Comment. — (i) and (2) The same comments made under (1) and (2) 
of the last operation apply equally here (page 305). (3) Owing to the greater 
proportion of skin in this covering and the division of muscles in one layer, 
as well as the number of tendons present in the sites where this method is 
generally used, the covering of the bones is not so satisfactory as in the ordinary 
circular method. 

MODIFIED CIRCULAR AMPUTATION 

(MIXED METHOD). 

General Description. — Two equal flaps, composed of skin and fascia, 




Figs. 303 and 304.— Modified Circular Method of Amputation: — A, Position of incision and 
bone-section ; B, Resulting suture-line. 



of varying length, and having bases equal to one-half of the circumference 
of the limb at their upper ends, are cut and dissected up a short distance — 
followed by a circular sweep of the knife through the retracted superficial 
muscles — and by a second circular sweep at a higher level, through the re- 
tracted deeper muscles — and completion of the operation as in the ordinary 
circular amputation. 

Technic. — Having fixed upon the saw-line, and having marked a point 
below the saw-line equal to \ of ih diameters of the limb at the saw-line (that 



OVAL METHOD OF AMPUTATION. 307 

is, three-fourths of the diameter at the saw-line), two equal flaps of skin and 
fascia (of this length) are planned. These flaps have bases equal to 
one-half the circumference of the limb at the level of their upper limit 
— and their length will be equal to one-third or one-half of the total distance 
between saw-line and lowest limit of skin-covering (generally one-third in 
slender, ill-formed limbs, and often one-half in large, tapering limbs). The 
flaps are usually lateral ones, but may be anterior or posterior (Fig. 303, A). 
Retracting the skin with the left hand, begin the incision at one mid-lateral 
aspect of the limb, at a level above the lowest limit of the skin incision equal to 
one-third or one-half (as the case may be) of the distance between the saw-line 
and the lowest limit of the skin incision — pass vertically downward, through 
skin and fascia, until nearly at the level of the lowest skin incision — thence 
round forward into the line of lowest skin incision, in a bluntly rounding 
manner — and complete the opposite end of the same flap in the same manner. 
Then make the opposite flap in the same way as the first one, corresponding 
in shape and size. Dissect these flaps of skin and fascia back to just beyond 
their bases. While the flaps, and the muscles also, are retracted, divide the 
more superficial muscles circularly — retract these, and divide the deeper 
muscles similarly — making the usual provision for the musculo-periosteal 
covering. The operation is completed as in the ordinary circular ampu- 
tation — the skin and fascial flaps being sewed over the quilted muscles — 
the bone being at the apex of a funnel which is somewhat shallower than 
in the infundibuliform variety of circular amputation (owing to the muscles 
having been divided at a higher level). 

Resulting Stump. — While not covering the end of the bone with quite 
as thick a padding of soft parts, its general features are the same as those 
following the ordinary circular method. The main part of the scar is terminal, 
but its ends are apt to be partly lateral (Fig. 304, B). 

Indications. — This is the form of circular amputation most generally 
used and is adapted to a greater number of sites than the ordinary circular, 
or the cuff modification of the ordinary method. 

Comment. — (1) The skin-flaps may be cut of unequal lengths. (2) 
The muscles may be divided at one level. (3) This form of circular ampu- 
tation has largely replaced either of the other forms. 



OVAL METHOD OF AMPUTATION. 

General Description. — A modification of the circular method. The 
skin incision is in the form of an oval, with one of its ends more prolonged 
and pointed — the soft parts between skin and bone being divided by cutting 
from without inward — and the lips of the wound being sutured in a single 
line parallel with the long axis of the wound. 

Technic. — This amputation being generally used in disarticulations, the 
upper or pointed end of the oval usually begins just above a joint-line and 
upon its outer or anterior aspect — the limbs of the oval parting at an angle 
sufficient to include the head of the distal bone — and sweeping thence in 
a curve down the lateral aspects of the limb — passing, finally, transversely 
toward each other — to meet upon the inner or under surface of the distal 
limb and at a distance beneath the line of articulation calculated to furnish 
sufficient covering for the head of the proximal one of the bones making up the 
joint (Fig. 305, A). Having completed the incision through skin and fascia, one 
of two courses may then be adopted ; — (a) The incision may then be deepened 



308 



AMPUTATIONS. 



throughout direct to the bone, by cutting from without — the deep incision, 
from the point where the arms or limbs of the oval begin to diverge, following 
the line of the retracted skin. This is the general method in all of the smaller 

disarticulations and in most of the larger, 
(b) Or the joint may be opened by the 
more vertical part of the incision and, after 
disarticulation, the muscles may be cut 
from within outward, on a line with the re- 
tracted skin. Having tied the vessels and 
cut the nerves and tendons short, the wound 
is sutured in its long axis (Fig. 307, B). 

Resulting Stump.— The end of the 
bone is very fully covered except where 
the head or articular end of the proximal 
bone is disproportionately large. The scar 
is termino-lateral (Fig. 307, B). 

Indications. — A form of amputation 
generally used for disarticulating a limb 
from the trunk, or a smaller limb from 
a larger limb. The method admits of 
first opening the joint for investigation 
before finally deciding upon amputation — 
and it also admits of securing the vessels 
before removing the limb. 

Comment. — The suture-line may run 
antero-posteriorly in one straight line — 
or the free, lower convex border of the 
flap may be turned over and sutured 
to the upper angular concavity of the wound. 




Fig. 305.— Oval Mkthod of Ampi 
TATion : — A, Form and position of oval 
B, Resulting suture-line. 



RACKET METHOD OF 
AMPUTATION. 

General Description. — 
A modification of the cir- 
cular method. The same, 
in principle, as the oval am- 
putation — with the addition 
of a longitudinal vertical cut 
prolonged from the apex of 
the oval forming the " han- 
dle of a racket" — thus 
giving a better exposure of 
joints without sacrifice of 
tissue and securing a better 
covering for the bone in the 
upper part of the wound. 

Technic. — Practically 
similar to the oval amputa- 
tion, except that the queue 
of the racket begins con- 
siderably farther back over 





Figs. 306 and 307.— Racket Method of Amputation: — A 
Form and position of incision ; B, Resulting suture-line. 



AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. 309 

the head of the proximal bone forming the joint — and along this single 
straight line the knife travels some distance before the arms of the racket 
begin to diverge. After the beginning of the divergence of the limbs of the 
racket, the operation is completed as in the oval operation (Fig. 306, A). 

Resulting Stump. — More satisfactory covering is secured by the racket 
than by the oval method of amputating. The scar is termino-lateral (Fig. 
307, B). 

Indications. — Disarticulations of the shoulder- and hip-joints, and of 
the digits from the hand and foot (especially, in the latter instances, where 
a metatarsal or metacarpal bone is removed with the digit). As in the oval 
method, but to a much greater extent, does the racket method admit of a pre- 
liminary examination of the joint through the vertical portion of the incision, 
before deciding upon amputation. The vessels may also be secured before 
entirely separating the limb. The muscles in the stump are better preserved. 

Comment. — (1) The queue of the racket should be placed, if possible, 
over an intermuscular septum and be deepened in the septum. (2) Ampu- 
tation by a T-shaped incision is, practically, a form of racket incision. (3) 
The suture line may run antero-posteriorly (or from the outer to the inner 
aspect of the part), which is to be preferred. Or the upper portion of the 
queue may be sutured in this manner and the lower convex portion of the 
flap brought up and sutured to the angular concavity formed by the di- 
vergence of the lateral limbs of the racket. 



FLAP METHODS OF AMPUTATING. 

(a) Single Flap of Skin and Muscles; — (b) Single Flap of Skin; — (c) 
Equal Flaps of Skin and Muscles; — (d) Equal Flaps of Skin; — (e) Unequal 
Flaps of Skin and Muscles; — (f) Unequal Flaps of Skin; — (g) Elliptical 
Method; — (h) Unequal Rectangular Flaps of Skin and Muscle. 



AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. 

General Description. — A method of amputating whereby the stump 
is covered with a single flap derived from one aspect of a limb — and consists 
of skin, fascia, and muscles. Such an amputation involves the maximum 
sacrifice of bone. 

Technic. — Having fixed upon the saw-line (or line of disarticulation), 
a point is determined upon below this line, and on that aspect of the limb 
which is to furnish the flap, which will represent a distance below the saw- 
line equivalent to i| diameters of the limb at the saw-line. A flap is then 
marked out with a base equal in width to a half-circumference of the limb 
at the saw-line, and a length equal to i| diameters of the limb at that line. 
(Fig. 308, A). Grasping the limb as in the ordinary circular amputation, the 
knife is entered at the far upper end of the base of the flap, at a right angle to 
the skin — and passes vertically down the mid-axis of the limb to near the lower 
limit of the flap — where it forms a squarely or bluntly rounded corner to the flap 
— thence passes transversely along the lower limit of the flap — and completes 
the opposite limb of the flap symmetrically with the first limb. This incision 
passes through skin and fascia. When this integumentary flap has retracted, 
the muscles are cut obliquely on a line with its retracted edges, so directing 
the knife as to bluntly bevel the muscular portion as the knife cuts its way 



3io 



AMPUTATIONS. 



from without inward and upward. This incision passes obliquely through all 
the muscles and is planned to come down upon the bone at a distance beneath 
the saw dine equivalent to a good diameter of the bone at the saw-line, thus 
providing for a musculo-periosteal covering. The knife is then carried through 
the periosteum so as to form a musculo-periosteal flap with a base of half 
the bone at the sawdine and a length of once the diameter. The musculo- 
periosteal covering is then detached back to the saw-line. Divide the hitherto 
undisturbed soft parts on the opposite side of the limb by a circular sweep 
of the knife — passing through the skin and fascia of the half-circumference 





Figs. 308 and 309— Amputation by Single Flap of Skin and Muscle : — A, Form and position of 
incisions ; B, Resulting suture-line. 



a little below the level of the base of the single flap — and through the muscles 
on a level with the base of that flap, including the periosteum. Retract all 
the soft parts on the proximal side of the saw-line and divide the bone. Suture 
the musculo-periosteal flap over the bone, the free edge of the periosteal 
flap being sutured to the half-circumference of the opposite aspect of the 
periosteum. Quilt the lateral and terminal aspects of the cut muscles in the 
flap with the transversely cut ends of the muscles on the opposite side of the 
limb. Suture the terminal and lateral aspects of the skin of the flap tc the 
transversely divided skin of the opposite side. 

Resulting Stump. — The stump is at first well covered with muscle — 
and, when this atrophies, by the replacing fibrous tissue. The scar is lateral 
(Fig. 309, B). 



AMPUTATION BY EQUAL FLAPS OF SKIN AND MUSCLE. 311 

Indications. — Cases of injury so destroying the soft parts as to leave 
those of but one aspect available. Also in such cases as Farabeuf's amputa- 
tion of the upper third of the leg by a single external flap of skin and muscles, 
or Dubreuil's disarticulation at the wrist by a single external flap of skin 
and muscles. 

Comment. — (1) In all flaps, skin must be longer than muscle. (2) 
There is sometimes an excess of muscle in a flap, part of which should be 
removed in the process of beveling — but a fully muscled flap is generally 
desirable. (3) A flap of skin and muscle is more apt to live and makes a 
better covering than one of skin alone. (4) While the muscle tissue as such 
may not remain in the tissues of a stump, the muscle-fibers undergoing 
atrophy, yet the fibrous tissue matting and padding together of the parts 
is left in its place. (5) A single flap requires the maximum sacrifice of limb, 
one side of the limb furnishing the entire covering and the bone being con- 
sequently divided at a higher level. 



AMPUTATION BY SINGLE FLAP OF SKIN. 

General Description. — The features of this operation are practically 
the same as those of the amputation by a single flap of skin and muscles, 
except that the covering here consists entirely of skin. 

Technic. — Having incised through skin and fascia, this integumentary 
flap is dissected up from the muscles throughout, including all overlving 
fascia, and is retracted above the saw-line (or disarticulation-line) — when 
the bone is sawed or disarticulated, and the flap dropped over the end of 
the limb — its terminal aspect being sutured to the transversely divided skin 
of the opposite side. 

Resulting Stump. — -Very thinly covered, but as the skin so utilized is 
generally accustomed to pressure, the result is usually satisfactory. 

Indications. — Such localities as the knee-joint (disarticulation by a 
single anterior flap), or the elbow-joint (disarticulation by a single posterior 
flap). 

Comment. — (1) As this method is generally used in a disarticulation, a 
capsulo-periosteal covering may sometimes be provided. (2) Nutrition of 
a single flap of skin and muscle is more difficult to maintain than in the more 
ordinary methods — and the nutrition of a flap of skin alone is even harder. 
(3) Skin-flaps are more used now than formerly because, owing to rarer 
suppuration, their vitality can be more counted upon. 



AMPUTATION BY EQUAL FLAPS OF SKIN AND MUSCLE. 

General Description. — Coverings for the stump are gotten from two 
opposite aspects of the limb in the form of two flaps composed of all the 
soft parts covering the limb — having equal bases and lengths — and the 
allowance of skin being sufficiently in excess to well cover the muscles. 

Technic. — The preliminaries being the same as in the ordinary circular 
amputation, two flaps are marked out, each having a width of base equal 
to the half-circumference at the saw-line and a length equal to three-fourths 
of the diameter of the limb at that same line (Fig. 310, A). With a large scal- 
pel, incise along the outlined flaps, passing through skin and connective tissue. 
When these integumentary flaps have retracted, proceed to form the remainder 
of the flaps — cutting obliquely along the margin of the retracted skin, in such 



312 



AMPUTATIONS. 



a manner that the flaps will be bluntly (not thinly) beveled, directing the 
knife so that the beveling will be greatest (though not thin even here) at the 
tip, and thickest toward the base — and coming down upon the bone, or bones, 
a distance below the saw-line equal to a full diameter of the bone (or of the 
bigger bone) to allow for musculo-periosteal covering. At this level make 
a circular cut around the bone through the periosteum with a heavy knife 
— detach the musculo-periosteal covering of the bone upward to the saw-line 
— retract the soft parts — divide the bone — suture the musculo-periosteal 
covering— quilt the muscles — and suture the skin. 

Resulting Stump. — As a rule, excellently covered by substantial tissues. 
The scar is termino-lateral (Fig. 311, B). 




Figs. 310 and 31 1.— Amputation by Equal Mixed Flaps: — A, Form and position of incisions; B 

Resulting suture-line. 

Indications. — In the continuity of limbs (between joints) where the 
bone or bones are equally covered with soft parts. 

Comment. — (1) The simplest form of making double flaps is by two 
vertical incisions down the opposite sides of what has been begun as a circular 
method. (2) One flap may be cut from without inward, and the other by 
transfixion. (3) In very muscular limbs it makes the meeting of skin over 
muscles easier if about 2.5 cm. (1 inch) of skin and fascia are dissected up 
from the muscle, after marking out and dividing the skin and fascia, and 
then cutting the muscles to the bone in a beveling fashion. 



AMPUTATION BY EQUAL FLAPS OF SKIN. 

This operation is the same, in general contour and dimensions of the 
flaps, as the last — except that the covering here consists of skin only. 



AMPUTATION BY UNEQUAL FLAPS OF SKIN AND MUSCLES. 313 

Technic. — Having incised through skin and fascia, upon the same lines 
as in the last form of amputation, the two equal flaps of integumentary tissues 
are dissected up to a level below the saw-line which will allow of providing 
a musculo-periosteal covering — at this level the muscles, after retracting the 
skin, are circularly divided down to the bone — this circular incision is con- 
tinued, on the same level (one-half diameter of the bone below the saw-line) 
around and through the periosteum — the periosteum is then retracted, with 
the overlying muscles, to the saw-line— and the bone divided. The musculo- 
periosteal covering is then sutured over the bone — and the skin margins 
sutured together. 

Resulting Stump. — Thinly covered, no muscle being present — but is 
generally satisfactory in the localities where adopted. The scar is termino- 
lateral. 

Indications. — Where a satisfactory muscle covering is hard to secure — 
as in the lower third of the forearm and leg and in the ringers — the tendons 
predominating in these localities. 




Figs. 312 and 313.— Amputation by Unequal Mixed Flaps:— A, Form and position of incisions, 
and line of bone-section ; B, Resulting suture-line. 



AMPUTATION BY UNEQUAL FLAPS OF SKIN AND MUSCLES. 

General Description. — Coverings are furnished by two flaps taken 
from opposite aspects of the limb — each flap having a base equal to one- 
half circumference of the limb at the saw-line — and one flap having a length 
greater than the other. One flap usually furnishes one-third or two-thirds 
of the covering, and the opposite flap two-thirds or one-third — the longer 



314 AMPUTATIONS. 

flap generally coming from that aspect of the limb most thickly muscled. 
The flaps may bear any relation to each other in relative length — but the 
two flaps combined furnish a covering equivalent to i| diameters of the 
limb at the saw-line. 

Technic. — This amputation is identical, except as to the length of the 
flaps, with the amputation by equal flaps of skin and muscle (Fig. 312, A). 

Resulting Stump. — Generally well covered. With scar either entirely 
lateral or partlv lateral and partly terminal, dependent upon the preponderance 
of one flap over the other (Fig. 313, B). 

Indications. — Thigh and arm throughout, and upper parts of forearm 
and leg. 

AMPUTATION BY UNEQUAL FLAPS OF SKIN. 

General Description. — Coverings are of skin and fascia alone and 
are furnished by the two opposite aspects of the limb, in the form of two 
flaps having equal bases and unequal lengths. This amputation is identical 
throughout with the amputation by equal flaps of skin, except as to the 
length of the flaps. 

AMPUTATION BY UNEQUAL RECTANGULAR FLAPS OF SKIN AND 

MUSCLES. 

TEALE'S METHOD. 

General Description. — The general method of performing this operation 
is similar, in principle, to that for amputation by unequal flaps of skin and 
muscles — with the exception that the flaps are rectangular (instead of rounded) 
and of special dimensions. 

Technic. — Having fixed upon the saw-line, two flaps are marked out, 
having their bases at that line and extending downward as described below. 
Find the circumference of the limb at the saw-line. The longer flap is to 
have its length and its breadth equal to a half-circumference at the saw-line. 
The shorter flap is to be one-fourth of the length of the longer, and its breadth 
equal to the remaining half-circumference at the saw-line. The longer flap 
should be of the same width all the way down. The shorter flap will have 
a width at its free end equal to very nearly a half-circumference of the limb 
at the level where it terminates (as that level, in the case of the shorter flap, 
is so short a distance beneath the saw-line) (Fig. 314, A). Having marked out 
these flaps, which should be accurately measured, the vertical parts of the inci- 
sion should be made from above downward, connected at their lower ends by 
the transverse incision which marks the limit of the longer flap, and by another 
transverse incision across the opposite half-circumference of the limb, at the 
proper level, marking off the lower limit of the shorter flap. These incisions 
at first involve skin and fascia only. When retraction has occurred (making 
a difference in the transverse incisions only), they are deepened throughout 
to the periosteum. The vertical limbs of the flaps are first cut to the peri- 
osteum — then the lower transverse limit of the longer flap, which is dissected 
up above the lower limit of the shorter flap — which in turn is cut transversely 
to the periosteum and dissected up. When a level below the saw-line is 
reached equal to a half-diameter of the bone at the saw-line, a circular incision 
is made through the periosteum and a musculo-periosteal covering raised. 
All the soft parts are now retracted above the saw-line and the bone divided. 
The musculo-periosteal covering is sutured. The longer flap is bent over 



ELLIPTICAL METHOD OF AMPUTATION. 



315 



the end of the bone — its end being sutured to the end of the shorter flap — 
the lateral aspects of the shorter flap are sutured to the lateral aspects of the 
longer — and the lateral aspects of the bent-over portion of the long flap are 
sutured to the contiguous lateral aspects of the unbent portion of the long 
flap. The muscles are quilted prior to suturing the skin. The part is well 
supported by splint, with only light pressure over the bent longer flap. 

Resulting Stump. — An H -shaped cicatrix is formed upon the aspect 
of the limb furnishing the shorter flap. The end of the bone is well covered 
when the long flap contains a preponderance of muscle — less well covered 
when containing a preponderance of tendons (Fig. 315, B). 




Figs. 314 and 315.— Amputation by Unequal Mixed Rectangular Flaps :— A, Form and position 
of incisions, and line of bone-section ; B, Resulting suture-line. 



Indications. — In the lower part of the leg (where the longer flap is taken 
from the anterior aspect) — and sometimes in the lower forearm (where the 
longer flap comes from the posterior aspect). 



ELLIPTICAL METHOD OF AMPUTATION. 

General Description. — This is not a distinct form of amputation. It 
may be considered a variety of the circular method (an oblique circular), 
or, equally, a variety of single-flap amputation — and may be held in an 
intermediate position. It is circular, as to skin incision; and flap, as to its 
manner of covering the stump and in the suturing. The skin incision is in 
the form of an ellipse, or a lozenge, the upper part of the ellipse being upon 
one aspect of the limb and the lower part upon the opposite — the lateral 
limbs of the figure crossing the lateral aspects of the limb to be amputated. 



316 



AMPUTATIONS. 



The idea of the ellipse is brought out by imagining the outline projected upon 
a fiat surface. 

Technic. — Having fixed upon the saw-line (or line of disarticulation), 
a point is determined above this, on, say, the posterior aspect of the limb, 
which is just above the saw-line — this becomes the highest point of the ellipse. 
The point marking the lowest point of the ellipse is placed upon the opposite 
side of the limb, at a distance below the saw-line equal, approximately, to 
i£ diameters of the limb at the saw-line (as there is but this one source of 
covering). Between these two points the lateral limbs of the ellipse pass, 
crossing the lateral aspects of the limb to be operated obliquely, from above 
downward, and so planned as to give a well-rounded convex termination of the 
ellipse below to be brought up and fitted into a corresponding concavity above 
(Fig. 316, A). The incision first passes around the outline of the ellipse, 

through skin and fascia only. 
Around the lower three- 
fourths of the line of this 
retracted skin and fascia a 
second incision passes through 
the muscles to the bone. The 
soft parts (skin and muscles) 
forming the lower part of the 
ellipse (the part that is to 
remain attached to the limb 
which is to be retained) are 
now dissected up from the 
bone to a point sufficiently 
below the upper limit of the 
ellipse to allow a musculo- 
periosteal or capsulo-perios- 
teal covering to be raised, and 
then on up to just below the 
upper limit of the ellipse (that 
is, to the saw-line or line of 
disarticulation). This large 
single mass of soft parts is 
well retracted — and the mus- 
cles on that aspect of the limb 
opposite to the one furnishing 
the muscles in the elliptical 
covering are circularly divided — and the limb sawed, or disarticulated, pre- 
serving the periosteum in the usual way. The lower convexity of the ellip- 
tical flap is now sutured into the upper concavity left by the part of the limb 
removed — the musculo-periosteal, or capsulo-periosteal, covering and the 
muscles being treated in the general manner by buried gut sutures — and the 
skin wound closed. 

Resulting Stump. — The ellipse is generally taken from a locality which 
affords a plentiful covering for the extremity, which is thus well provided for. 
The scar is lateral (Fig. 317, B). 

Indications. — Chiefly used for disarticulations — especially at the elbow 
and wrist, and in the supramalleolar amputation. 

Comment. — The muscle portion of the ellipse may be cut also by trans- 
fixion, although, as usual, less satisfactorily. 





B 



Figs. 316 and 317.— Amputation by the Ellipticai 
Method : — A, Form and position of incision ; B, Re- 
sulting suture-line. 



SELECTION OF AMPUTATION METHOD. 317 

OSTEOPLASTIC AMPUTATIONS. 

Description. — An osteoplastic operation, in general, consists in the approx- 
imation of fresh sections of bone to each other, for the purpose of bringing 
about union between their opposed surfaces. In an osteoplastic amputation, 
some portion of a distal bone is raised in the form of an osseoperiosteal flap, 
adherent to its neighboring soft parts, and applied to the sawed aspect of the 
proximal bone. In performing osteoplastic amputations a special saw should 
be provided — a bow-saw with a scroll-blade of strong, narrow, thin metal, 
which can be turned in any direction while in the act of making bone-sections, 
such as the Helferich pattern of saw. (A saw for osteoplastic work is now 
on trial which is, practically, a Gigli saw held in a bow-handle.) The freshened 
surfaces of bone are variously held in contact — the edges of the surrounding 
periosteum may be sutured together — the bone surfaces may be wired, pegged, 
or nailed — or the bone aspects may be held in apposition (especially where 
there is no strong counter-pull) by the simple suturing of the surrounding 
soft parts together. 

Objects of the Osteoplastic Method of Amputation. — (i) Closure 
and protection of the medullary canal; — (2) Securing of a solid end of bone 
to meet pressure — brought about by the rounding off of the section of bone 
whose surface becomes united with the end of the main bone; — (3) Avoidance 
of adhesions between sawed bone and soft coverings — and, by retaining the 
mobility of these parts, thereby lessening the chance of neuralgia and ulcera- 
tion in the stump. 

Application of the Osteoplastic Method of Amputation. — Up to the 
present time the chief sites at which this method of amputation has been 
used have been in the lower extremity — that is, where pressure-bearing stumps 
are sought. The following are examples of the osteoplastic method of ampu- 
tation; — Pirogoff's osteoplastic amputation of the foot (page 415) — Lister's 
modification of Carden's transcondyloid amputation of the thigh (page 440) — 
Gritti-Stokes's supracondyloid amputation of the thigh (page 441) — Sabane- 
jeff's amputation of the thigh (Figs. 367, 368, 369) — Bier's amputation of the 
leg (Figs. 360, 361, and 362). 

IRREGULAR METHODS OF AMPUTATION. 

This is a special feature of modern-day surgery. Formerly amputations 
were done upon hard and fast lines. Now there is a marked tendency to 
allow the method of amputation to be determined by the special features 
and need of the individual case — and, as a result, irregular amputations 
are more commonly done, which, while accomplishing the general indica- 
tions, are not bound by any set rule, shape, or measurement. The practical 
surgeon, therefore, should, on common-sense ground, adapt his method of 
amputation to the case in point, rather than be bound by any fixed form of 
amputation. The greatest field for irregular forms of amputation is in 
cases of injury and deformity, rather than in disease. 

SELECTION OF AMPUTATION METHOD. 

Many considerations enter into the determination of the best method 
of amputation in a particular case — and the choice should be given to that 
method which promises to fulfil the greatest number of the following features; — 

Characteristics of Good Amputation Methods. — (1) Minimum sacri- 



318 AMPUTATIONS. 

fice of healthy tissue — (2) Best permanent bone-covering — (3) Small wound 
area — (4) Good blood-supply to stump — (5) Favorably placed cicatrix — (6) 
Efficient drainage — (7) Simplicity of method — (8) Vessels and muscles cut 
transversely — (9) Possibility of getting satisfactory musculo-periosteal covering 
— (10) Ease of exposing bone at saw-line — (n) Ease of bringing soft parts 
together over bone without tension — (12) Adjustability of artificial limb— 
(13) Largest range of adaptability — (14) Shapeliness of resulting stump— 
(15) Rapidity of method. 

Comment. — Circumstances may determine the selection of an ampu- 
tation method known in advance not to be the best — for instance, owing 
to the increased mortality in approaching the trunk, a limb may be removed, 
in a case where the vitality of the patient demands that every chance be 
given him, at a level which, while increasing his chances for life, may not 
furnish the best covering. Again, in amputating about the hand, it may 
conserve the interest of the patient better to be satisfied with even a partial 
flap and allow the remainder to heal by granulation, rather than remove 
an additional \ cm. (\ inch) of an important finger. Rapidity of method 
used to be the chief consideration, but is now the last in importance, except 
in special instances — other considerations taking precedence — the operation 
being done with deliberation and precision. 

Features of the Circular Method of Amputating. — (1) Minimum 
sacrifice of bone and soft parts of any method. — (2) Bone especially well 
covered in the infundibuliform variety. Conical stump sometimes follows 
retraction, especially in the cuff and modified varieties of the circular. — (3) 
Smallest wound area of any method. — (4) Tissues of stump well supplied 
with blood. — (5) Cicatrix terminal. — (6) Efficient drainage when sutured 
antero-posteriorly. — (7) Most simple of any method. — (8) Main vessels and 
muscles cut transversely. — (9) Musculo-periosteal covering well provided. 
— (10) Exposure of bone at saw-line not always easy. — (n) Not always 
easy to bring soft parts together over bone. — (12) Terminal cicatrix favorable 
for hollow artificial limbs; unfavorable for solid limbs of lower extremity. — 
(13) Unfavorable for amputation following injury involving the aspects of 
the limb to unequal heights. — (14) Somewhat greater tendency to become 
conical. — (15) Most rapid of any method. 

Features of the Flap Method of Amputating. — (1) Greater sacrifice 
of bone and soft tissues (especially in unequal flaps). — (2) Coverings of bone 
can be more largely regulated to suit demand. Conical stumps less apt to 
follow than after the cuff and modified forms of the circular. — (3) Greater 
wound area. — (4) In long flaps the blood-supply may not be so satisfactory. — 
(5) Terminal or termino-lateral cicatrix — can be planned as desired. — (6) 
Drainage as efficient as in the circular if the flaps be lateral. Not so efficient 
if the flaps be antero-posterior. — (7) Not so simple as the circular. — (8) 
Muscles divided obliquely; vessels also, and latter may be split up. — (9) 
Musculo-periosteal covering well provided. — (10) Bone easily exposed at 
the saw-line. — (n) Flaps easily brought together over bone. — (12) Terminal 
cicatrix favorable for any hollow artificial limb. Terminal portion of termino- 
lateral cicatrix pressed upon by solid lower limb, and lateral portion pressed 
upon by any hollow artificial limb. — (13) Favorable for amputations following 
injury involving the aspects of the limbs unequally. Adaptable to any part 
of any limb. — (14) Stump apt to be more shapely than that of the circular. — 
(15) Less rapid than the circular. 

Circumstances Influencing Death-rate After Amputation. — The 
death-rate is greater; — (1) The nearer the amputation is to the trunk — (2) 



QUALITIES OF A GOOD STUMP. 319 

In the lower than in the upper limbs — (3) Fur injury than for disease — (4) 
In men than in women — (5) Between the ages of five to fifteen than before 
or after. In a tabulation of 3600 amputations performed by himself, Estes 
has found that, as far as the upper extremity is concerned, there is no appreci- 
able difference in fatality following amputations through the various parts of 
the hand, forearm, and arm, until the shoulder-joint is reached, where, naturally, 
the maximum mortality for the upper extremity occurs. In the case of the 
lower extremity, on the other hand, there is an increase in mortality from ampu- 
tations from the foot upward, as the lower limb is ascended, reaching the 
maximum for the whole body at the hip-joint. 

Influence of Age upon Amputations. — The young and old, especially 
if feeble, stand the actual operation less well than those in the reverse condi- 
tions — and also tolerate the subsequent confinement and apparatus less well. 



PRIMARY, INTERMEDIATE, AND SECONDARY AMPUTATIONS. 

In amputations done for disease the time for operation may be selected 
which will coincide with the patient's best condition to meet the procedure. 
Amputations done for injury are either Primary (performed immediately after 
the reception of the injury) — Intermediate (in the course of wound-repair) 
and Secondary (after healing). In primary amputations the operation should 
be done at once, if the general condition of the patient permit. If the con- 
dition of shock (from psychical effect and blood loss) contraindicate imme- 
diate interference, stimulation, intravenous infusion, the application of heat, 
and the like, should be resorted to, and the limb removed during the reaction- 
ary period (generally within thirty-six hours). If the condition of shock is 
thought to be kept up by the damaged limb, amputation should be done at 
once, the above measures of revival being maintained the while. 



THE AMPUTATION STUMP. 
QUALITIES OF A GOOD STUMP. 

Firm in consistency — well covered — insensitive — of regular and symmetrical 
contour. The death-rate and the quality of the stump determine the success 
of any form of amputation. The following features are characteristic of a 
good stump — and also indicate the changes which follow successful ampu- 
tation: — 

Skin. — Not adherent, except at cicatrix. Capable of withstanding (and, 
preferably, accustomed to withstand) pressure. Plentifully supplied with 
blood. 

Muscles. — The muscles of a stump are not retained as such — the muscle 
tissue disappears in greater part and is replaced by fibrous tissue. Ex- 
ceptionally some muscle tissue remains and continues to function. The 
mass of fibrous tissue which replaces it, however, serves a useful purpose 
in padding over the end of the bone. In brief, muscle tissue tends to de- 
crease — and fibrous tissue to increase. Muscles and tendons either become 
incorporated in the cicatrix, form new attachments to bone, or retract out 
of the way. 

Bone. — The ends of the bones become rounded and the medullary 
canals closed bv fibrous tissue. The end of the bone may either dwindle 



320 AMPUTATIONS. 

and atrophy, or the periosteum may, exceptionally, deposit an excess of bone. 
The shaft of the bone in an amputated limb also atrophies somewhat. 

Cartilage. — Following a disarticulation, the articular cartilage left 
atrophies and sometimes entirely disappears. 

Nerves. — Also atrophy to a greater or less extent. The ends generally 
become bulbous, but give no trouble unless they become adherent to bone 
or cicatrix. 

Vessels. — Share in the general atrophy, and dwindle to a size com- 
mensurate with the parts to be supplied. Ligated trunks become obliterated 
to their nearest branch. Collateral circulation is established. 



CHARACTERISTICS OF A BAD STUMP. 

In contradistinction to the general qualities of a good stump, a bad stump 
may be flaccid, scantily covered, sensitive, of irregular contour — and may 
be further characterized by the following conditions: — 

Skin. — Thin, scanty, tightly drawn, adherent, puckered — cold or purple 
from improper circulation— ulcerated from the same cause, or from trophic 
changes — involved with corns — and may become malignant. 

Muscles. — See the changes mentioned in the last section. 

Connective Tissue. — Bursae may form. 

Bone. — Osteitis, periosteitis, and necrosis may occur. 

Two special forms of bad stump are met: — 

Painful Stump. — May be due to osteitis or periosteitis— but is generally 
due to compression of the nerve. The nerve may be directly pressed upon 
by new bone or fibrous tissue — may be stretched over the stump — or may 
be the seat of neuritis. The end of a painful nerve is generally bulbous — 
but not necessarily — for often normal-looking nerve-ends are sensitive, and 
bulbous ones non-sensitive. 

Conical Stump. — The end of the bone forms the apex of a cone which 
may be the result of one or more of the following causes — (i) Flaps cut too 
short — or bone too long. — (2) Sloughing or suppuration of the soft parts. — 
(3) Post-operative contraction of muscles. — (4) Growth of the bone from 
an active epiphysis in the young. 

Comment. — Unfavorable changes are less apt to occur in case of primary 
union than in the reverse. 



CONDITIONS INFLUENCING VITALITY OF STUMP. 

(1) Blood-supply — full or scant, impeded or unobstructed by position 
of stump-covering. — (2) Compression by bandage, dressing or splint. — (3) 
Tightness and unnatural position of flaps, as compared with easy and natural 
position. — (4) Full allowance of skin and non-separation of skin from muscle, 
as compared with the reverse. — (5) Long and loose tendons and aponeuroses. 
(6) Too rapid sawing of bone. — (7) Finally, site of amputation, manner of 
performing the operation, prior local condition, prior constitutional con- 
dition, and after-treatment — all influence the vitality of the stump. 

Comment.— The chief dangers to be avoided, are — over-tension in the 
skin and muscle covering — insufficient blood-supply — rough projections of 
bone and laceration of the parts — and inclusion of nerves in the cicatrization. 

Immediate Complications of Amputations. — Spasm of muscles; hemor- 
rhage from nutrient artery of bone, and general post-operative hemorrhage. 



FUNCTION OF AMPUTATION STUMPS. 32 1 

CONTRACTILITY OF THE TISSUES OF THE STUMP. 

Skin. — The average contractility of the skin is equivalent to about one- 
third of its length. It is most contractile where thinnest — where the sub- 
cutaneous tissue is least — where its attachment to underlving parts is least 
— where it is least stretched by movements — and where the process of healing 
has been longest. It is least contractile where the opposite conditions exist. 

Muscles. — The extremes of muscular contractility vary from a slight 
separation of divided parts up to a retraction of four-fifths of their length. 
Contractility is primary, where it occurs at the time of the operation — and 
secondary, where it occurs subsequent to the operation. Muscles contract 
most — which are freest between origin and insertion — which have long 
fibers — and where the process of healing has been longest. The larger the 
muscle, the greater the amount left in the flap, and the younger and healthier 
the subject, the greater the contraction. Muscles contract least where the 
conditions are the reverse of those just mentioned. 

Skin, Fascia, and Muscles. — The average contractility of the mixed 
tissues of a flap, or covering, is generally equivalent to about one-third of 
the length of the flap, or covering. Additional length, however, should be 
allowed, in calculating the length of coverings — (1) When the transverse 
section of the bone is large as compared with the transverse section of the 
soft parts — (2) When the amputation is considerably below the origin of the 
muscle involved — (3) When secondary retraction is expected. 



POSITION OF STUMP-CICATRICES. 

The cicatrix should be so placed as to be the least exposed to pressure 
after the healing of the wound. 

With Reference to Their Position. — Scars may be Terminal — at the 
end of the stump; — Lateral — on one or more sides of the stump; — Termino- 
lateral — occupying the end and side of the stump. 

With Reference to Their Production. — The following methods of 
amputation produce the following kinds of scars; — Circular is followed by 
terminal scar; — Elliptical, by lateral scar, if the ellipse be oblique, and terminal 
if the ellipse be nearly horizontal; — Oval, by termino-lateral; — Racket, by 
termino-lateral; — Single flap, by lateral scar; — Double flap, by terminal scar, 
if the flaps be equal, and lateral if the flaps be unequal. 

Comment. — (1) Other things being equal, that method of amputation 
should be chosen which will bring the scar in the most favorable position 
for that particular case — and especially with reference to the subsequent 
functioning of the stump and its adaptability to an artificial limb. (2) In 
amputating in some situations the muscles of one group being so much stronger 
than those of another, will often draw a scar, terminal at the time of opera- 
tion, much higher up upon one aspect than it will be drawn on the opposite 
aspect. Calculations for such an occurrence have, therefore, to be made. 



FUNCTION OF AMPUTATION STUMPS. 

In the Upper Extremity. — The chief function of the stump in the upper 
extremity is range of movement and power to wield an artificial limb, rather 
than to bear pressure and weight. As the chief pressure of an artificial limb 



322 AMPUTATIONS. 

comes upon the lateral aspects of the stump, the scar of the stump in the 
upper extremity is best when terminally placed. 

In the Lower Extremity. — The chief function of the stump in the lower 
extemity is to bear pressure and weight. As the chief pressure of a solid 
artificial limb comes upon the end of the stump, the scar of the stump in the 
lower extremity is best when laterally placed — in those cases in which 
a solid artificial limb is to be worn. As, however, most modern artificial 
limbs for the lower extremity, for the better classes, are hollow, there is not 
now made the same difference as formerly. 

The Modern Type of Artificial Limb. — While the above was particu- 
larly true of the older, cruder forms of artificial limbs (and is still true of the 
peg-leg), the modern forms of artificial limbs are nearly always made upon 
the basis of a light, hollow cone, and are so adjusted as to largely adapt 
themselves to the conditions found — and, generally speaking, most of the 
pressure is of the lateral aspects of the stump and living limb against the 
sides of the hollow cone of the artificial limb — so that pressure is exercised 
upon the lateral aspects of the living stump and limb rather than upon the 
end — and in the lower as well as in the upper extremity. 

Comment. — A function of the stump of the upper extremity, especially 
about the hand, and more particularly of a woman, is to be as symmetrical 
and shapely as possible, in the case of partial sacrifice of that member. While 
in the case of a laborer it would certainly be better to sacrifice appearance 
to strength and utility, one might be urged to sacrifice strength for appearance 
in the case of a woman of the non-working class. 



SITE OF AMPUTATION IN CONNECTION WITH THE RESULTING 
STUMP AND ITS ADAPTABILITY TO AN ARTIFICIAL LIMB. 

The choice of the site of amputation is determined by the resulting mortality 
and the fitness of the stump for an artificial limb. Concerning the effect of 
the amputation site upon mortality, see Circumstances Influencing the Death- 
rate after Amputation (page 318). 

In general, the longer the stump, the more useful the limb. 

Considerable responsibility rests with the surgeon in choosing the site and 
technic of operation, which will leave the patient the best stump, circumstances 
considered, adaptable to an artificial limb. 

While formerly it was taught to save every fraction of limb possible, it is 
now regarded as better for the patient's interest to select that site and form of 
amputation furnishing a stump best suited to take an artificial limb of the 
widest range of function. 

In planning the form of skin covering, it is to be remembered that if the 
scar be not terminal, it should be somewhat posterior or lateral, rather than 
anterior, as the movement to force an artificial limb forward causes the appa- 
ratus to press upon an anterior scar. For the same reasons the ends of divided 
bones which lie near the skin, which is generally their anterior aspect, should 
be rounded, so as not to be pressed by the false limb. 

In calculating an efficient stump distal to a joint, sufficient length below 
the joint must be provided to bear upon and wield or swing the artificial limb. 
Every additional inch is here a matter of importance. 

The primary function of the upper artificial limb is for prehension — of the 
lower, to bear weight and admit of locomotion. 



SURGICAL ANATOMY OF THE FINGERS. 323 

As the main growth in the length of the humerus and femur is from the 
upper epiphysis, amputation through the shaft of these bones, in the young, 
will almost certainly be followed by a conical stump, which will often require 
re-amputation. 

In the lower extremity an osteoplastic amputation is preferable, where 
feasible — especially in operating for disease, where a deliberate calculation 
can be made. 

The general tendency of the day, in operating about the foot, is to regard the 
foot as a whole, irrespective of joint-lines, and to amputate along improvised 
lines adapted to the special case. 

Classical and irregular amputations through the tarsus, though condemned 
by artificial-limb makers, and though supposed by some to yield too large a 
proportion of sensitive stumps, should be performed in preference to ampu- 
tations above the ankle. 

The lower third of the leg is the place of election in amputating through the 
leg — rather than the formerly given "hand's breadth" below the knee-joint. 
In the latter case too limited a length of bone is left for good leverage in adapt- 
ing a false limb. The site of choice is at the junction of the middle and lower 
thirds of the leg — thus leaving room for an artificial ankle-joint. 

Under no circumstances amputate through the tibia higher than 8 cm. 
(3 inches) below its superior articular surface. 

In amputating in the neighborhood of the knee-joint, one of the osteoplastic 
operations by which a piece of bone from the tibia is approximated to the sawn 
end of the femur in the condyloid region serves an useful purpose, furnishes 
a stump that will bear pressure well, and generally leaves room for the artificial 
knee-joint in approximately a normal position. 

Amputation through the thigh 8 cm. (3 inches) above the knee-joint gives 
ample room for an artificial joint in a normal position. 

Amputations through the thigh higher than its middle do not furnish as 
satisfactory stumps as those at and below this level. 

In operating above the knee, however, it is to be borne in mind that the 
weight is also borne by the ischio-perineal region. 



AMPUTATIONS AND DISARTICULATIONS OF THE UPPER 

EXTREMITY. 

SURGICAL ANATOMY OF THE FINGERS. 

Bones. — Third, second, and first phalanges of the fingers; — and second 
and first phalanges of the thumb. 

Articulations and Ligaments. — (a) Second Interphalangeal Articula- 
tions; anterior; two lateral; capsule. Posterior ligament not present — place 
supplied by united tendons of extensor communis digitorum and extensor 
indicis, for index; — extensor communis digitorum for middle and ring; — 
united tendons of extensor communis digitorum and extensor minimi digiti, 
for little finger, (b) First Interphalangeal Articulations; — anterior (glenoid); 
two lateral; capsule. Posterior ligament not present — place supplied by 
extensor longus pollicis (extensor secundi internodii pollicis) for thumb; — 
united tendons of extensor communis digitorum and extensor indicis, for 
index; — extensor communis digitorum, for middle and ring; — united tendons 
of extensor communis digitorum and extensor minimi digiti, for little finger, 
(c) Metacarpo-phalangeal Articulations; — anterior; two lateral; capsule. 



324 AMPUTATIONS. 

Posterior ligament — not present as distinct ligament — place supplied by 
scattered fibers from one lateral ligament to opposite lateral ligament; ex- 
tensor brevis pollicis (extensor primi internodii pollicis) ; extensor longus 
pollkis (extensor secundi internodii pollicis), for thumb; — and the same 
ligaments for the other fingers as those for the first interphalangeal joints. 

Sesamoid Bones. — Two on palmar surface of metacarpophalangeal 
joint of thumb, developed in inner and outer heads of flexor brevis pollicis, 
which here replace the anterior ligament. One or two on palmar surface 
of metacarpophalangeal joint of index and little fingers. Rarely one on 
palmar surface of metacarpophalangeal of middle and ring fingers. Rarely 
one on palmar surface of interphalangeal joint of thumb. 

Muscles and Tendons. — (A) Of Fingers in General; — (a) On palmar 
aspect; — flexor sublimis digitorum; flexor profundis digitorum. (b) On 
dorsal aspect of index; — united tendons of extensor communis digitorum 
and extensor indicis; first dorsal interosseous (abductor indicis). On dorsal 
aspect of middle finger; — extensor communis digitorum; second dorsal 
interosseous; third dorsal interosseous. On dorsal aspect of ring finger; — 
extensor communis digitorum; fourth dorsal interosseous; second palmar 
interosseous. On dorsal aspect of little finger; — united tendons of extensor 
communis digitorum and extensor minimi digiti; fourth lumbrical; third 
palmar interosseous, (c) On ulnar aspect of little finger; — abductor minimi 
digiti; flexor brevis minimi digiti. (B) Of Thumb; — (a) On palmar aspect; 
— flexor longus pollicis. (b) On dorsal aspect; — extensor brevis pollicis 
(extensor primi internodii pollicis) ; extensor longus pollicis (extensor secundi 
internodii pollicis). (c) On radial aspect; — abductor pollicis; outer head of 
flexor brevis pollicis. (d) On ulnar aspect; — inner head of flexor brevis 
pollicis; adductor obliquus pollicis; adductor transversus pollicis. 

Sheaths (Thecae). — Processes of palmar fascia extending down fingers 
from palm of hand to bases of last phalanges, being attached to lateral margins 
of first phalanges, and forming sheaths for flexor tendons. 

Synovial Membranes. — (a) Of index, middle, and ring fingers; — extend 
from base of last phalanges up to bifurcation of palmar fascia, namely, about 
opposite necks of metacarpals (corresponding, approximately, to middle 
crease on palm of hand, for index, and to lowest crease for middle and ring), 
(b) Of thumb and little finger; — extend from base of last phalanges to and 
into great synovial sac of hand. 

Nails. — Overlie the soft parts covering the distal two-thirds of the last 
phalanges on their dorsal aspect. 

Arteries. — (a) Palmar Supply; — Four palmar digital branches of super- 
ficial arch; radialis indicis of deep arch; princeps pollicis of deep arch, (b) 
Dorsal Supply; — Second and third dorsal interosseous branches of posterior 
radial carpal branch of radial; first dorsal interosseous (metacarpal) branch 
of radial; dorsalis indicis branch of radial; dorsalis pollicis branch of radial. 

Veins. — (a) Superficial; — digital (one on each side), (b) Deep; — venae 
comites. 

Lymphatics. — One lymphatic vessel on dorsal and one on palmar aspect 
of each side of each finger. 

Nerves. — (a) Median supplies — thumb, index, middle, and ring fingers, 
(b) Ulnar supplies — ring, little, and middle (sometimes), (c) Radial supplies 
— thumb, index, middle, and ring. 



GENERAL CONSIDERATIONS IN FINGER AMPUTATIONS. 325 



SURFACE FORM AND LANDMARKS OF THE FINGERS. 

The proximal ends of the phalanges form the knuckles — and therefore 
the joint-line is beyond the knuckle. The interphalangeal joint-lines are 
found, with approximate accuracy, by flexing the distal phalanges at a right 
angle with the proximal phalanges (or metacarpals) — and then prolonging 
the mid-lateral axis of the proximal bone forward — this line will pass through 
the center of the joints. More accurately, the last interphalangeal joint is 
2 mm. (yV inch), the first interphalangeal joint 4 mm. (^ inch), and the meta- 
carpophalangeal joint 8 mm. (J inch) beyond the prominence of the knuckle. 

The sesamoid bones can be felt in front of the metacarpo-phalangeal 
joint of the thumb. 

The palmar aspects of the fingers are crossed by three series of transverse 
folds; — the highest are single for the index and little fingers, double for the 
middle and ring — and are nearly 2 cm. (f inch) below the metacarpo-phalan- 
geal joints; — the middle are double for all the fingers — and are directly 
opposite the first interphalangeal joints; — the lowest are single for all the 
fingers — and are a little above the second interphalangeal joints. The 
thumb has two folds — the higher, single, crosses the metacarpo-phalangeal 
joint obliquelv; — the lower, single, directly opposite the first interphalangeal 
joint. 

The free margin of the webs of the fingers is about 2 cm. (f inch) below 
the metacarpo-phalangeal joints. 

The lateral ligaments of the joints are nearer the palm than the dorsum. 

The sheaths of the flexor tendons extend from the metacarpo-phalangeal 
joints to the proximal ends of the third phalanges — are least distinct opposite 
the joints — gape when cut — and lead into the palm of the hand. 

The digital arteries bifurcate about 8 mm. (J inch) above the free margin 
of the webs of the fingers. 

The epiphyses form the heads of the four inner metacarpals, the base 
of the first, and the bases of all the phalanges — all joining the shaft about 
the twentieth year. 

The skin of the palm is thick, dense, and adherent — that of the dorsum, 
thin and loosely connected to the fascia. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS OF THE 

FINGERS. 

Minimum sacrifice of tissue is the rule in all amputations about the fingers 
— especially in thumb, index, and little fingers — so that there may be left 
some length of digit, no matter how short, to approximate to other digits 
and objects grasped. The basal principle here is — (a) Save a stump, no 
matter how imperfect — (b) provided tendons remain connected to it, or can 
be sutured to it — (c) and sound skin can be found to cover it. Indeed, the 
last may be dispensed with, if there seem fair chance that granulation will 
cover over the part. Amputations here, especially in cases of injury, are 
often irregular operations, and amount to little more than trimming of mangled 
parts — as a bony stump of irregular form, provided flexion and extension 
exist, is better than a shorter stump of more symmetrical contour. 

Since the bones of the fingers are large, as compared with the surrounding 
soft parts, an ample allowance of covering should be made. 



326 AMPUTATIONS. 

In the interphalangeal region the joints are concave from side to side, 
with the concavity toward the finger-tips. In the metacarpo-phalangeal 
region the convexity is toward the tips. 

Owing to the function of the fingers, cicatrices should be planned to fall 
out of the way of pressure — should not be terminal or palmar — and are best 
placed on the dorsum. 

The stump of a phalanx is often considerably in the way unless the flexor 
and extensor tendons can act upon it. Formerly all of a finger below the 
center of the middle phalanx (where the superficial flexor is attached) was 
sacrificed. Now, however, the flexor tendon is sutured into the mouth of 
the cut theca and periosteum, or even the flap, thereby securing control 
of the phalangeal stump. 

The fibrous sheaths of the flexor tendons gape open when cut across 
and their channels lead directly into the palm of the hand, and those of the 
thumb and little finger into the great synovial sac beneath the annular ligament 
of the wrist, furnishing a ready avenue for possible infection. They should, 
therefore, be closed by two or three catgut sutures, passed from the palmar 
to the dorsal aspect of the sheath with a curved needle, whenever cut in the 
course of an amputation about the fingers. But when cut, especially when 
the finger is extended, the flexor tendons draw up into the sheath out of 
sight, and if the sheaths were then sutured the action of the flexor tendons 
upon the phalangeal stump would be lost. Therefore, to give the flexor 
tendons a firm hold upon the part, the sutures should include flexor tendon, 
theca, and periosteum — passing, in order, from before backward, through 
anterior wall of theca, flexor tendon (if distal to center of middle phalanx), 
or tendons (if proximal to center of middle phalanx), and posterior wall of 
theca, which is blended with the periosteum. Where the theca is imperfect, 
the tendons should be sutured to neighboring periosteum, glenoid ligament, 
adjacent fibrous tissue, or into the tissues of the flap. Thus the mouth of 
the sheath is closed by the tendon while anchoring the latter to the part. 
This sheath is absent over the terminal phalanx and over the distal inter- 
phalangeal joint — and is indistinct over the metacarpo-phalangeal joint. 
Where absent, the flexor tendons should be sutured into the neighboring 
structures, as just described. Where the periosteum is to be included in the 
suture, it should be stripped back before dividing the bone. 

If the base of the terminal phalanx be saved, the attachment of the deep 
flexor is preserved. If the upper third of the second phalanx be saved, the 
attachment of the superficial flexor is preserved. If the amputation be 
through the first interphalangeal joint, or proximal to it, both flexor tendons 
will be lost — unless they are sutured into the neighboring structures as just 
described (into theca, periosteum, or flaps). 

The best form of amputation for all parts below the metacarpo-phalangeal 
joint is one in which a palmar flap predominates — furnishing a covering 
of thick, sensitive skin accustomed to pressure — and a cicatrix on the dorsum. 

In disarticulations by the palmar flap method, a slight downward con- 
vexity given to the transverse dorsal incision gives a better apposition with 
the palmar flap than would a straight transverse incision over the dorsum 
of the joint. 

Disarticulation is best accomplished from the dorsum, after flexing the 
joint — cutting, in order, through the following structures — skin; fascia; 
extensor tendons (attached to the bases in the interphalangeal joints, and 
forming the posterior ligaments of the joints); dorsal portion of the capsule; 
the knife passing thence behind the base of the distal bone and cutting the 



AMPUTATION THROUGH LAST PHALANX OF FINGERS. 327 

lateral ligaments from within outward; anterior portion of capsule, from 
within; and anterior ligament, also from within. 

The glenoid ligament, the fibro-cartilaginous plate which is mainly attached 
to the base of the distal bone, should be left in the stump. 

A longitudinal cut made in the mid-lateral aspect of the finger will have 
the digital arteries on the palmar side. 

All flaps should be cut from without inward — none by transfixion. 

The heads of the metacarpals should be preserved, especially in those 
who require strength in their hands. Their removal weakens the hand. If left 
in, they and their soft overlying parts eventually atrophy to some extent and 
the gap is not so apparent. If removed, somewhat greater symmetry is 
acquired at the cost of strength. 

Musculo-periosteal coverings in these small amputations through the 
phalanges are often difficult to provide, but should be provided where possible 
— even a periosteo-capsular covering in disarticulating. 

In making all palmar incisions, the part should be extended — and flexed 
while making dorsal incisions. The fullest coverings will be thus secured. 

Guard against making flaps too narrow and pointed — the heads of the 
bones to be covered are all large, following disarticulation. 

All incisions outlining the different amputations pass through only skin 
and fascia at first. 

All ligatures should be catgut — and the skin sutures either silk or silkworm- 
gut. 

In all amputations about the fingers the stump should be snugly dressed 
and bandaged, and an anterior splint should be included in the dressing. 



AMPUTATION THROUGH LAST PHALANX OF FINGERS, IN GENERAL. 

Best Form. — Palmar Flap. 

Comment. — The palmar flap method furnishes the best form of covering 
— and, owing to the presence of the nail, is about the only available form 
of amputation in this locality. 



AMPUTATION THROUGH LAST PHALANX OF FINGERS 

BY PALMAR FLAP. 

Description. — Single palmar flap of all tissues down to bone. 

Position (for all Amputations about the Fingers). — Patient on back; 
upper extremity held out from body, or, better, supported on a small table; 
hand pronated and fingers flexed while dorsal incisions are made, and hand 
supinated and fingers extended during palmar incisions. Assistant stands 
in front of surgeon, between him and shoulder of patient — steadying the hand 
with both of his own and holding the adjacent fingers out of the way. Surgeon 
holds digit to be removed with thumb and forefinger of left hand — with 
back of thumb downward and his hand pronated during palmar incisions — ■ 
and with his thumb upward and his hand supinated during dorsal incisions. 

Landmarks. — The space is so limited that the saw-line can only be 
placed between the matrix of nail and proximal end of second phalanx. 

Incision. — (1) Palmar incision — from saw-line downward along lateral 
aspect of phalanx, midway between dorsal and palmar surfaces, around the 
center of the pulp, and back to the saw-line on the opposite side. (2) Dorsal 



328 



AMPUTATIONS. 



incision — connects upper ends of palmar incision, passing transversely over 
the dorsum with slight downward convexity. (For principle, see Fig. 318, C, 
and 319, B, where disarticulation at the last interphalangeal joint is shown.) 




Fig. 318.— Amputations about the Finger :— A, Through first phalanx, by equal palmar and 
dorsal flaps ; B, At first interphalangeal joint, by long palmar and short dorsal flaps ; C, At second 
interphalangeal joint, by palmar flap. 

Operation. — Having outlined these incisions, carry the palmar incision 
to the bone — dissect up all palmar tissues down to the bone — deepen the 
dorsal incision to the bone — retract the soft parts, in the entire circumference 
- — and saw the phalanx with a light saw, while holding the tip of the phalanx 




Fig. 319. — Amputations about the Thumb: — A, Disarticulation of thumb at carpo- 
metacarpal joint by oval incision; B, Disarticulation at metacarpophalangeal joint by oblique 
palmar flap; C, Disarticulation at interphalangeal joint by palmar flap. 

with bone-holding forceps (as there is generally too little room for the fingers 
of the operator to grasp). Ligate the palmar digital artery on each side. 
Suture the deep flexor tendon to the periosteum or flap. Suture the palmar 
flap to the transverse dorsal line. 



DISARTICULATION THROUGH SECOND JOINT OF FINGERS. 329 

DISARTICULATION AT SECOND INTERPHALANGEAL JOINT OF 
FINGERS, IN GENERAL. 

Best Method. — Palmar Flap. 

Other Methods. — Short Dorsal and Long Palmar Flaps. 
Comment. — Even where the double flap method is adopted, the covering 
must be almost entirely palmar, owing to the position of the nail. 



DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 

OF FINGERS 

BV PALMAR FLAP 

Position. — As for amputation through last phalanx (page 327). 

Landmarks. — Second interphalangeal joint-line. 

Incisions. — (1) Palmar incision — begins opposite the joint-line, midway 
between dorsal and palmar surfaces — passes down lateral aspect for a distance 
equal to i| diameters of the finger at the disarticulation-line — crosses palmar 
aspect with bluntly rounded corners — and passes upward to the corresponding 
point on the opposite side of the finger. (2) Dorsal incision — connects upper 
end of palmar incision by a transverse incision made over dorsum of joint, 
with slight downward convexity (Fig. 318, C). 

Operation. — Having outlined these incisions through skin and fascia, 
carry the palmar incision to the bone on a line with the retracted skin — and 
dissect the soft parts up from the bone. Deepen the dorsal incision to 
the bone, along the line of retracted skin — open the joint from the dorsum 
and disarticulate from within outward. There is no theca here to close. 
Suture the deep flexor tendons into the neighboring tissues. Ligate the two 
digital arteries. Suture the palmar flap to the dorsal line. 

Comment. — The joint is sometimes first disarticulated by a transverse 
dorsal incision — and the palmar flap then cut from within outward — but 
with less satisfactorv result. 



DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 

OF FINGERS 

BY SHORT DORSAL AND LONG PALMAR FLAPS. 

Position — Landmarks. — As in the last operation. 

Incisions. — (1) Palmar flap — little more than length of diameter of 
finger at disarticulation-line — begins at disarticulation-line, in mid-lateral 
aspect of finger — passes directly down the finger for the above distance — 
crosses the palm with bluntly rounded corners— and passes up the finger to 
the corresponding site upon the opposite side. (2) Dorsal flap — one-third 
the length of the palmar — beginning and ending at the same points as the 
palmar — and crossing the dorsum with bluntly rounded corners at the above 
distance below the upper limit. (For principle, see Fig. 318, B.) 

Operation. — Carry these incisions to the bone on the lines of retracted 
skin, completing the palmar incision first — dissect the soft parts from the 
bone up to the joint-line — open the dorsal aspect of the joint and disarticulate 
— completing the operation as in the above method. 



330 AMPUTATIONS. 

AMPUTATION THROUGH SECOND PHALANX OF FINGERS, IN 

GENERAL. 

Best Methods. — Palmar Flap; Short Dorsal and Long Palmar Flaps. 

Other Methods. — Equal Dorsal and Palmar Flaps; Equal Lateral 
Flaps; Single External Flap (for index); Single Internal Flap (for little finger); 
Circular; Oblique Circular; Dorsal Flap. 

Comment. — Any single flap, unless taken from the palm, brings part of 
the scar into the palm. A dorsal flap gives a palmar scar. All equal flap 
methods and circular methods give terminal scars. 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS 

BY PALMAR FLAP. 

Position. — As for amputation through last phalanx (page 327). 

Landmarks. — Lines of proximal and distal joints. 

Incisions. — (1) Palmar incision — begins opposite saw-line in mid-lateral 
aspect of finger — passes vertically downward a distance equivalent to ij 
diameters of the finger at the saw-line — crosses the palmar aspect with bluntly 
rounded corners — passes vertically upward in the mid-lateral aspect of the 
opposite side to a point corresponding with the one of beginning. (2) Dorsal 
incision — connects the upper limits of the limbs of the palmar incision, 
passing transversely across the dorsum with slight downward convexity. 
(For principle, see Fig. 318, C.) 

Operation. —The above incisions are now deepened to the bone, the 
palmar first and then the dorsal, on a line with the retracted skin. The 
soft parts are dissected off the bone back to the saw-line and are retracted 
while the bone is being sawed. Ligate the digital arteries. In amputating 
distally to the upper third of the second phalanx, the superficial flexor tendon 
will retain its attachment. The deep flexor tendon will, however, be 
severed and should be sutured into the mouth of the fibrous sheath (which 
ends at the middle of the second phalanx) and into neighboring periosteum 
and soft parts, if necessary — the closure of the sheath being accomplished 
in the process of anchoring the deep flexor tendon. The flap is then 
sutured in the usual way. 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS 

BY SHORT DORSAL AND LONG PALMAR FLAPS. 

Position — Landmarks. — As in the last operation. 

Incisions. — (1) Palmar Flap — (2) Dorsal Flap — both outlined exactly 
as in the disarticulation through the second interphalangeal joint by short 
dorsal and long palmar flaps — with the necessary calculations for the change 
in position (page 327). (For principle, see Fig. 318, B.) 

Operation. — For the technic of the operation, see the disarticulation 
just mentioned. For the manner of dealing with the structures encountered, 
see the operation last described. 



AMPUTATION THROUGH FIRST PHALANX OF FINGERS. 33 1 



DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF 
FINGERS, IN GENERAL. 

Best Methods. — Same as mentioned under amputation through second 
phalanx (page 330). 

Other Methods. — Same (page 330). 
Comment. — Same (page 330). 



DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF FINGERS 

BY PALMAR FLAP. 

Position. — As in amputation through last phalanx (page 327). 

Landmarks. — First interphalangeal joint-line. 

Incisions. — As for disarticulation at second interphalangeal joint by 
palmar flap (page 329). (For principle, see Fig. 318, C.) 

Operation. — Same, in principle, as the disarticulation at the second 
joint of the fingers. Both flexor tendons are here severed below their inser- 
tions, and the use of the proximal phalanx would be much interfered 
with unless these tendons were securely attached to the sheath, periosteum, 
or glenoid ligament of the stump. 

DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF 

FINGERS 

BY SHORT DORSAL AND LONG PALMAR FLAPS. 

Position — Landmarks. — As in the last operation. 

Incision. — Same as in disarticulation at the second interphalangeal joint 
(page 329). (For principle, see Fig. 318, B.) 

Operation. — Same as in the operation just referred to (page 329). For 
treatment of the flexor tendons, see disarticulation at first interphalangeal 
joint by a palmar flap (page $^, 1) . 



AMPUTATION THROUGH FIRST PHALANX OF FINGERS , IN GENERAL. 

Best Methods. — Palmar Flap; Short Dorsal and Long Palmar Flaps. 

Other Methods. — Same as mentioned under amputation through second 
phalanx (page 330). To which list may be added the oval method. 

Comment. — Same as made under the operation just referred to (page 
33o)- 

AMPUTATION THROUGH FIRST PHALANX OF FINGERS 

BY PALMAR FLAP. 

Position. — As for amputation through last phalanx (page 327). 

Landmarks. — Lines of metacarpophalangeal and first interphalangeal 
joints. 

Incisions — Operation. — Same as for amputation through second phalanx 
(page 330). For reference to flexor tendons, see under disarticulation at 
first interphalangeal joint by palmar flap (page 331). 



332 AMPUTATIONS. 

AMPUTATION THROUGH FIRST PHALANX OF FINGERS 

BY SHORT DORSAL AND PALMAR FLAPS. 

Position — Landmarks. — As in the above operation. 

Incision — Operation. — As for amputation through the second phalanx 
by the same method (page 330). For reference to treatment of the flexor 
tendons and sheaths, see under disarticulation at first interphalangeal joint 
by palmar flap (page 331). 



DISARTICULATION OF FINGERS AT METACARPO-PHALANGEAL 
JOINTS, IN GENERAL. 

Best Methods. — Oval Method (for fingers in general and for thumb); 
Externo-palmar Flap of Farabeuf (for index) ; Interno-palmar Flap of Fara- 
beuf (for little finger); Oblique Palmar Flap (for thumb). 

Other Methods. — Equal Lateral Flaps; Circular Incision, joined by 
vertical dorsal queue; Palmar Plap; Large External and Small Internal 
Flaps (for index); Large Internal and Small External Flaps (for little finger). 

Comment. — The first four are the best in the sites indicated and are 
superior to the others mentioned. The oblique palmar flap for the thumb 
gives the best covering where sufficient tissue exists. 



DISARTICULATION OF FINGERS, IN GENERAL, AT METACARPO- 
PHALANGEAL JOINT. 

BY OVAL METHOD. 

Description. — The queue is placed over the dorsum of the joint and 
the center of the oval passes across the palmar aspect at the web-line. 

Position. — As for amputation through the last phalanx (page 327). 

Landmarks. — Head of metacarpal; metacarpo-phalangeal joint-line; 
web of finger. 

Incision. — Begins just above head of metacarpal, on its dorsal aspect 
(in the position corresponding with its neck) — passes down the median dorsal 
aspect over the prominence of the knuckle, to just beyond the base 
of the first phalanx (which is about midway between the metacarpo- 
phalangeal joint-line and the free edge of the web) — at this point the hitherto 
median incision diverges into two symmetrical limbs — each sweeping across 
the dorso-lateral aspect of the finger to just below the junction of the finger 
with the web — and thence transversely across the palmar surface in the 
line of the crease, on a level with the free border of the web, coming to the 
opposite side just below the junction of the web with the finger. This rather 
extensive incision is best made with three strokes — from commencement to 
web of one side — from point of divergence of median line to web of opposite 
side — and across palmar surface connecting the two limbs (Fig. 320, H, and 
321, E). 

Operation. — The above incision through skin and fascia is now deepened. 
The palmar portion is cut to the bone while the finger is forcibly extended. 
The lateral portions are carried to the bone, cutting the lumbricales and 
interossei. The soft parts are retracted to the joint-line. The extensor 
tendons are then cut and the joint thus entered from the dorsum — the lateral 



METACARPO-PHALANGEAL DISARTICULATION OF THUMB. 333 

ligaments and glenoid ligament being cut from within and the disarticulation 




Fig. 320.— Amputations about the Fingers, Hand, and Wrist : — A, Through second phalanx 
of little finger, by single internal flap ; B, At first interphalangeal joint, by oval method ; C, Through 
second phalanx, by equal lateral flaps; D, Through second phalanx of index, by single external flap ; 
E, Through first phalanx, by oblique circular; F, Through first phalanx, by ordinary circular ; G, 
At metacarpophalangeal joint of little finger, by interno-palmar flap; H, At metacarpophalangeal 
joint, by oval method ; I, At metacarpophalangeal joint of index, by externo-palmar flap ; J, Of little 
finger at carpo-metacarpal joint, by racket method ; K, Same of ring finger; L, Of middle finger and 
part of metacarpal, by racket method ; M, Of two inner fingers at carpo-metacarpal joints, by racket 
method ; N, Of thumb at carpo-metacarpal joint, by racket method ; O, Through metacarpophalan- 
geal joint of thumb, by oblique palmar flap ; P, P, At wrist-joint, by external flap. 



completed. The two digital arteries are tied and the synovial sheath closed. 
The edges of the sides of the oval are sutured in one vertical, antero-posterior 



,334 AMPUTATIONS. 

line, in continuation with the queue of the incision. The splint applied 
should include the wrist-joint. 

Comment. — (i) The joint may be opened from the palmar surface, by 
cutting the glenoid ligament transversely against the base of the metacarpal. 
In either case, the glenoid ligament is retained. (2) No attempt is made to 
attach the flexor tendons, as the entire finger is removed and there would 
be nothing for them to flex. (3) The lower end of the vertical cicatrix is 
eventually drawn up out of the way of palmar pressure. (4) If it be desired 
to remove the head of the metacarpal, prolong the queue of the incision 
upward — free the neck of the bone of soft parts, hugging the bone in the 
process — retract the soft parts — and, while partly lifting the metacarpal 
from its bed by traction upon the finger, if still attached, or by grasping the 
head of the bone with bone-forceps, if disarticulation have occurred, pass 
a chain or Gigli saw beneath the bone and make a section, so as to bevel the 
bone obliquely from behind downward and forward, and from the inner- 
or outer aspect toward the median aspect (Fig. 321, C and D). (5) Where 
the skin of the palm is very dense and hard, as in laborers, an awkward pro- 
jection of skin may be left on the palmar surface of the convexity of the oval, 
which can be removed and make the suturing more satisfactory by cutting 
out a V-shaped portion from the palmar aspect. This, however, amounts, 
practically, to lateral flaps, and brings part of the scar into the palm. (6) 
Avoid cutting into the web. 



DISARTICULATION OF THUMB AT METACARPO-PHALANGEAL JOINT 

BV OVAL METHOD. 

Position. — As in amputation through last phalanx (page 327). 

Landmarks. — Neck of first metacarpal; metacarpo-phalangeal joint. 

Incision. — Begins on dorsal aspect of neck of metacarpal, to ulnar side 
of median line — passes directly down over head of bone and along median 
aspect of extensor tendons, or slightly to ulnar side, to just beyond the base 
of the metacarpal — thence the median incision diverges — each limb passing 
obliquely across the dorso-lateral borders of the thumb, so as to cross and 
meet upon the palmar aspect opposite the center of the first phalanx (Fig. 
3i9, A). 

Operation. — Deepen this incision to the bone along the line of the re- 
tracted skin — dividing the extensor brevis pollicis and extensor longus pollicis 
opposite the metacarpo-phalangeal joint, and the flexor longus pollicis 
opposite the middle of the first phalanx. The sesamoid bones are to be 
detached from the base of the first phalanx and left in the stump. As far 
as possible the muscles which are attached to the base of the first phalanx 
(extensor brevis pollicis, adductor obliquus pollicis, adductor transversus 
pollicis, abductor pollicis, flexor brevis pollicis), as well as the long flexors 
and extensors, should be sutured into the tissues of the stump — as considerable 
range of movement is thereby secured for the metacarpal bone, whereby 
it may offer counterpressure to the fingers. Close the synovial sheath. Tie 
the dorsalis pollicis and two branches of the princeps pollicis. Suture the 
oval in a single straight line in continuation of the queue. 

Comment. — The head of the metacarpal is large and requires ample 
covering. 



METACARPOPHALANGEAL DISARTICULATION OF INDEX-FINGER. 335 
DISARTICULATION OF THUMB AT METACARPO-PHALANGEAL JOINT 

BY OBLIQUE PALMAR FLAP — (FARABEUF). 

Description. — This method consists of two U-shaped incisions, the 
dorsal having its convexity upward, the palmar having its convexity down- 
ward — the limhs of each U passing, and obliquely meeting, on the lateral 
aspects of the thumb. 

Position. — As for amputation through the last phalanx (page 327). 

Landmarks. — Lines of the metacarpophalangeal and interphalangeal 
joints. 

Incision. — The convexity of the dorsal U is upward and corresponds 
with the dorsal aspect of the metacarpophalangeal joint. The convexity 
of the palmar U is downward and is placed just above the interphalangeal 
joint-line. Between these two rounded extremities the lateral limbs pass 
in an oblique direction along the lateral borders of the thumb, becoming 
continuous with each other (Fig. 320, O, and 319. B). 

Operation. — This incision is deepened throughout to the bone, along 
the line of the retracted skin — the extensor brevis pollicis and extensor longus 
pollicis are divided over the metacarpophalangeal joint, and the flexor 
longus pollicis about the center of the first phalanx — the soft parts are freed 
back to the joint-line — the sesamoid bones are detached from the base of 
the first phalanx and left in the Map — the joint is entered from above and 
disarticulation completed. The dorsalis pollicis and the two branches of 
the princeps pollicis are to be tied. The synovial sheath is closed. The 
convexity of the palmar flap is sutured into the concavity of the dorsal wound 
— bringing the cicatrix well on to the dorsum and out of the way of pressure 

Comment. — As the head of the metacarpal is disproportionately large, 
an additional allowance of covering must be made. 



DISARTICULATION OF INDEX-FINGER AT METACARPO-PHALANGEAL 

JOINT 

P.V EXTERNO-PALMAR FLAP— (FARABEUF). 

Description. — This is really an oval method, so modified as to bring 
the cicatrix upon the interno-dorsal aspect of the metacarpophalangeal 
region — so that fingers and objects opposed to that aspect may not come 
into contact with the scar. 

Position. — As for amputation through last phalanx of finger (page 327). 

Landmarks. — Metacarpophalangeal joint-line; middle of first phalanx; 
web. 

Incision. — Begins at metacarpophalangeal joint-line, immediately over 
the median aspect of the extensor tendon — passes vertically down the median 
dorsal aspect of the finger, in the above relation to the extensor tendon, to 
the center of the first phalanx — thence sweeps across the lateral and palmar 
aspects to the web — and thence passes in a straight line, by the shortest 
route, up the inner side of the finger to the place of beginning (Fig. 320, I). 

Operation. — This superficial incision is deepened to the bone — the soft 
parts retracted to the joint-line — disarticulation effected — and the operation 
completed as in the simple oval method. The digital, dorsalis indicis, and 
radialis indicis arteries are to be tied. The flexor sheath is to be closed — 
and the parts so sutured as to cause the cicatrix to occupy the position of the 
straight portion of the incision, upon the interno-dorsal aspect. 



336 AMPUTATIONS. 

Comment. — (i) The placing of the incision over the median, or even 
slightly to the ulnar, rather than the radial aspect of the extensor tendon 
(as recommended by Farabeuf), gives ampler covering, and a greater cer- 
tainty of the scar falling well to the ulnar side. (2) If the head of the meta- 
carpal be removed, it is exposed as mentioned under the oval method (page 
334, Comment). 

DISARTICULATION OF LITTLE FINGER AT METACARPOPHALANGEAL 

JOINT 

BV INTERNO-PALMAR FLAP— (FARABEUF). 

Description. — This, also, is a modification of the oval method, so cal- 
culated as to bring the cicatrix upon the externo-dorsal aspect of the meta- 
carpophalangeal region — that non-scar tissue may come into contact with 
objects which press the stump. 

Position — Landmarks. — As in the last operation. 

Incision. — Begins at the metacarpo-phalangeal joint-line, immediately 
over the median aspect of the extensor tendon — passes vertically down the 
dorsal aspect of the finger, in the above relation to the extensor tendon, to 
the center of the first phalanx — thence sweeps across the lateral and palmar 
aspects of the finger to the web — and thence passes in a straight line, by the 
shortest route, up the radial side of the finger to place of beginning (Fig. 
320, G). 

Operation. — The steps of the disarticulation are completed as in the 
corresponding operation just described upon the thumb, the reverse of which 
this is, in every respect. Two digital arteries are to be tied. The parts 
are to be so sutured as to cause the cicatrix to occupy the position of the 
straight portion of the incision, upon the externo-dorsal aspect of the region, 
buried in the groove formed by the adjacent finger. 

Comment. — (1) Carrying the incision over the median aspect of the 
extensor tendon insures more covering than if the incision passed down the 
ulnar aspect, as recommended by Farabeuf — and also makes it more certain 
that the scar will fall well to the radial side of the stump, out of the way of 
pressure. (2) If it be desired to remove the head of the metacarpal, it is 
exposed as described under the oval method of disarticulating the fingers in 
general — the bone being here beveled from ulnar to radial aspect, and from 
dorsum to palm. 



SURGICAL ANATOMY OF THE HAND. 

Bones. — (a) Metacarpals, of thumb and fingers; — (b) Carpals; — First 
Row; scaphoid, semilunar, cuneiform, pisiform; — Second Row; trapezium, 
trapezoid, os magnum, unciform. 

Articulations and Ligaments. — (A) Metacarpophalangeal Articula- 
tions; — See description under Surgical Anatomy of Fingers. (B) Meta- 
carpals with each other (Intermetacarpal) ; — (a) Carpal ends of four inner 
metacarpals; — dorsal, palmar, and interosseous ligaments, and synovial 
membrane; — (b) Digital ends of four inner metacarpals; — transverse meta- 
carpal ligaments (on palmar aspect). (C) Inner Metacarpals with the 
carpus; — dorsal, palmar, and interosseous ligaments, and synovial membrane. 
(D) Metacarpal of thumb with trapezium; — capsular ligament. (E) Articu- 
lations of second row of carpals with each other; — three dorsal, three palmar, 
and three interosseous ligaments, between trapezium and trapezoid, between 



SURGICAL ANATOMY OF THE HAND. 337 

trapezoid and os magnum, and between os magnum and unciform; and 
synovial membrane between each. (F) Articulations of carpals of first row 
with each other; — two dorsal ligaments between scaphoid and semilunar, 
and between semilunar and cuneiform; two palmar ligaments between scaphoid 
and semilunar, and between semilunar and cuneiform; two interosseous 
ligaments between scaphoid and semilunar, and between semilunar and 
cuneiform; capsular ligament between cuneiform and pisiform; two palmar 
ligaments between pisiform and unciform process of unciform, and between 
pisiform and fifth metacarpal; and synovial membrane between each bone. 
(G) Articulations of two rows of carpals with each other (medio-carpal) ; — 
palmar, dorsal, external lateral and internal lateral ligaments, and synovial 
membrane (between each row). 

Anterior Annular Ligament. — (a) Attachments; — Internally; pisiform 
and unciform process of unciform bone. Externally; tuberosity of scaphoid 
inner part of anterior surface, and ridge on trapezium. Superiorly; con 
tinuous with deep fascia of forearm. Inferiorly; continuous with palmar 
fascia, and furnishing attachment to some of muscles of thumb and little 
finger, (b) Structures passing superficial to anterior annular ligament (from 
without inward) ; radial vessels and nerve, flexor carpi radialis, palmaris 
longus, ulnar vessels and nerve, flexor carpi ulnaris. (c) Structures passing 
beneath anterior annular ligament (from above downward) ; flexor sublimis 
digitorum, median nerve, flexor profundus digitorum, flexor longus pollicis. 

Posterior Annular Ligament. — (a) Attachments; — Internally; styloid 
process of ulna, cuneiform and pisiform bones. Externally; outer margin 
of radius and elevated ridge on its posterior surface. Superiorly; continuous 
with deep fascia of forearm, (b) Tendons passing beneath posterior annular 
ligament (in six compartments, from without inward) ; — (1) extensor ossis 
metacarpi pollicis and extensor brevis pollicis; (2) extensor carpi radialis 
longior and brevior; (3) extensor longus pollicis; (4) extensor communis 
digitorum and extensor indicis; (5) extensor minimi digiti; (6) extensor 
carpi ulnaris. 

Synovial Sacs. — Two synovial sacs lie beneath the anterior annular 
ligament, one for the flexor sublimis digitorum and flexor profundus digitorum, 
and one for the flexor longus pollicis. Both extend upward for 3 to 4 cm. 
(ij to ij inches) above the anterior annular ligament. That for the flexor 
longus pollicis extends downward to last phalanx of thumb. That for the 
flexor tendons of fingers divides into four processes; the one for the little 
finger generally extending to base of last phalanx; — those for index, middle, 
and ring fingers ending about middle of the metacarpals — and are thus 
separated by about 1.3 cm. (J inch) from the great synovial sac. Thus there 
is an open channel from the ends of the thumb and little fingers to a point 
3 or 4 cm. (1 J to 1 ^ inches) above the anterior annular ligament. 

Muscles and Tendons. — (i) Of palmar aspect : — (a) Superficial 
Muscles from Forearm; — Flexor carpi radialis; palmaris longus; flexor carpi 
ulnaris; flexor sublimis digitorum. (b) Deep Muscles from Forearm; — 
Flexor profundus digitorum; flexor longus pollicis. (c) Short, small Muscles 
of Thumb; — Abductor pollicis; opponens pollicis (flexor ossis metacarpi 
pollicis); flexor brevis pollicis; adductor obliquus pollicis; adductor trans- 
versa pollicis. (d) Short, small Muscles of Little Finger; — palmaris brevis; 
abductor minimi digiti; flexor brevis minimi digiti; opponens minimi digiti 
(flexor ossis metacarpi minimi digiti). (e) Short Central Muscles of Hand; 
— four lumbricals; three palmar interossei. (2) Of dorsal aspect :— (a) 
Superficial Muscles from Forearm; — Extensor communis digitorum; extensor 



33% AMPUTATIONS. 

minimi digiti; extensor carpi ulnaris. (b) Deep Muscles from Forearm;— 
Extensor ossis metacarpi pollicis; extensor brevis pollicis (extensor primi 
internodii pollicis); extensor longus pollicis (extensor secundi internodii 
pollicis); extensor indicis; extensor carpi radialis longior; extensor carpi 
radialis brevior. (c) Small Muscles of Dorsal Aspect of Hand; — four dorsal 
interossei. 

Attachment of Muscles to Bases of Metacarpals. — To first; extensor 
ossis metacarpi pollicis. To second; extensor carpi radialis longior; flexor 
carpi radialis. To third; extensor carpi radialis brevior. To fifth; extensor 
carpi ulnaris; some fibers of flexor carpi ulnaris. 

Arteries. — (a) Palmar supply: — (i) From Radial; — anterior radial 
carpal; superficialis yoke; deep arch; princeps pollicis; radialis indicis; three 
palmar interossei; three superior (posterior) communicating (perforating); 
three inferior (anterior) communicating (perforating); palmar carpal re- 
current. (2) From Ulnar; — anterior interosseous; anterior ulnar carpal; 
superficial palmar arch; four palmar digital; deep palmar (communicating); 
three palmar interossei (from deep arch, common to radial and ulnar) ; three 
superior (posterior) communicating (perforating) (also common to radial); 
three inferior (anterior) communicating (perforating) (also common to 
radial); palmar carpal recurrent (also common to radial), (b) Dorsal 
supply : — (i) From Radial; — radial; posterior radial carpal; dorsalis pollicis; 
dorsalis indicis; metacarpal (first dorsal interosseous); second and third 
dorsal interosseous; three superior (posterior) communicating (perforating); 
three inferior (anterior) communicating (perforating). (2) From Ulnar; — 
posterior ulnar carpal; metacarpal. 

Veins. — (a) Superficial; — Dorsal Venous Plexus — from which arise super- 
ficial radial vein, and anterior and posterior superficial ulnar veins; — Anterior 
Median Plexus — from which arise superficial median vein, (b) Deep; Two 
venae comites for each artery. 

Lymphatics. — Pass up the forearm from the lymphatic palmar arch, 
and from the dorsal plexus of lymphatics. 

Nerves. — (a) From Median; — Median and following branches; outer 
and inner palmar cutaneous; muscular branches; five digital branches; (b) 
From Ulnar; — Ulnar and following branches; palmar cutaneous; dorsal 
cutaneous; superficial palmar branch; deep palmar branch, (c) From 
Radial; — external branch; internal branch. 



SURFACE FORM AND LANDMARKS OF THE HAND. 

Carpal bones — two subcutaneous eminences may be felt upon the palmar 
aspect of the hand just below the wrist — the outer (just beneath the radial 
styloid process) due to the tuberosity of the scaphoid and ridge on the trape- 
zium (the ridge being just beneath the former) — the inner, due to the pisiform 
bone The unciform process of the unciform lies below and slightly internal 
to the pisiform. No other carpal bones are recognizable on the palmar 
surface — and only the cuneiform on the dorsum. 

Metacarpal bones — The heads of the metacarpals form the knuckles. 
The dorsal surface of the fifth, and the heads of all, are subcutaneous — all the 
other aspects of the remainder are covered by muscles or tendons. The base 
of the metacarpal of the thumb can be felt — and the sesamoid bones opposite 
the metacarpo-phalangeal joint. 

Skin-folds (creases) of the hand — (a) Superior fold — begins at wrist, 
between thenar and hypothenar eminences, and runs to the outer border 



SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT HANDS. 339 

of the hand at the base of the index-finger — and is formed by the adduction 
of the thumb, (b) Middle fold — begins at outer border of hand where supe- 
rior fold ends, and runs inward and slightly upward and ends at outer limit 
of hypothenar eminence — and is formed by the simultaneous flexion of the 
metacarpophalangeal joints of the first and second fingers — and about 
corresponds, opposite the third metacarpal, to the lower portion of the super- 
ficial palmar arch, (c) Inferior fold — begins opposite the cleft between 
the index and middle fingers and runs almost transversely to the ulnar margin 
of the hand, crossing the lower part of the hypothenar eminence — and is 
formed by the flexion of the middle, ring, and little fingers. It crosses the 
necks of the three inner metacarpals, and approximately indicates the upper 
limit of the synovial sheaths of the flexor tendons of the three outer fingers. 
Midway between this fold and the free margins of the webs are the meta- 
carpophalangeal joints. 

Line of carpo-meta carpal joints — from base of fifth metacarpal, to carpo- 
metacarpal joint-line of thumb (both of which may be recognized). The 
inner portion of this line is regular, the outer portion irregular. 

Line of metacarpophalangeal joint-line — found by flexing the first 
phalanges at a right angle with the metacarpals — and then prolonging the 
mid-lateral axis of the metacarpals forward — which lines will pass through 
the center of the joints. 

Free edges of webs of fingers, on palmar aspect, are about 2 cm. (f inch) 
below the metacarpophalangeal joints. 

Muscles — The muscles of the thenar (thumb) eminence — and .those of 
the hypothenar (little finger) eminence are recognizable, and also the ad- 
ductor transversus pollicis. The lumbricals form soft eminences behind the 
clefts of the fingers — and the dorsal interossei form similar soft eminences 
between the metacarpals. The position of many of the extensor tendons 
can be recognized by both sight and. touch — and some of the flexor tendons 
can be detected by touch while in the act of movement. 

Vessels — the superficial palmar arch is on a level with the lower border 
of the outstretched thumb, passing down from the wrist on the outer side 
of the pisiform. The deep palmar arch lies about 1.3 cm. (h inch) nearer 
the wrist, crossing the shafts of the second, third, and fourth metacarpals 
near their bases. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE HANDS. 

A finger may be removed with a part, or the whole, of its metacarpal. 
In the middle metacarpals, the removal of a part, where possible, is better 
than a disarticulation at the carpo-metacarpal joint — as the end of the bone 
is not apt to get into the way, and the strength of the hand is greater. In 
the case of the thumb and little finger, however (which are the fingers most 
frequently removed, because most exposed to injury), it is best to remove the 
entire metacarpal — the retention of a part of the outer metacarpals being 
of little value, and often in the way — and its removal not weakening the hand 
as much as the loss of an inner one. 

If but a part of the metacarpal of the thumb or little finger be removed, 
however, the remaining portion should be beveled obliquely away from the 
position of most pressure. 

The metacarpals should be divided in their continuity by a Gigli saw 
It is easier, but less surgical, to divide them with bone-cutting pliers. 



34° 



AMPUTATIONS. 




Fig. 321. — Amputations about Hand and Wrist: — A, Disarticulation of two inner fingers, 
together with their metacarpals, by curved racket incision; B, Disarticulation at wrist by equal 
anterior and posterior flaps; C, D, Oblique section of second and fifth metacarpals as sometimes 
practised in disarticulation at metacarpo-phalangeal joints of first and fourth fingers; E, Amputa- 
tion of part of metacarpal by oval method as sometimes performed in disarticulation at the 
metacarpo-phalangeal joints of the innermost and outermost fingers. 

Additional advantages in amputating a finger and part of its metacarpal, 
over disarticulating a finger and all of its metacarpal, are the following; — 
deep palmar arch is not exposed; synovial sacs of flexor tendons may escape, 



AMPUTATION OF FINGER WITH PART OF ITS METACARPAL. 341 

if the bone be divided above its center; carpo-metacarpal synovial sacs are 
not opened; and tendons attached to bases of metacarpals are not lost. 

Where, in disarticulating at the carpo-metacarpal articulation, the joint- 
line is not easily located before incising, begin the incision as high as thought 
to be the articular line, and then verify the line by inserting the tip of the 
index-finger into the wound, while the opposite hand manipulates the special 
finger whose metacarpal forms part of the articulation. 

As the metacarpal of the thumb and, according to some, of the little finger 
do not communicate with the large synovial sac of the carpal bones, they 
can be removed in their entirety with little danger of infection — but, in un- 
clean cases, the removal of the second, third, and fourth metacarpals in their 
continuity is preferable to a disarticulation at the carpo-metacarpal line, 
with the likelihood of general infection. 

The synovial sheaths should be closed with gut-suture when cut. But 
where large synovial sheaths and extensive articular surfaces are opened up, 
drainage for twenty-four or forty-eight hours is indicated. 

In partial amputations of the hand, the flexor and extensor tendons should 
be cut long enough to be sutured into the wound, so as to retain flexion and 
extension of the stump. 

The main dangers in amputating and disarticulating about the hand 
are wounding of the deep palmar arch or termination of the radial, and in 
opening the synovial sheath of the palm or fingers. 

The stump should be dressed upon a splint which will immobilize the 
wrist. 



AMPUTATION OF FINGERS, IN GENERAL, WITH PARTS OF THEIR 

METACARPALS. 

Methods. — Racket Method — best for single fingers, in general, as well as 
for thumb and little finger; and also for two or three continguous inside 
fingers. Equal Dorsal and Palmar Flaps — best for the three inner fingers. 
Anterior Ellipse (sometimes called a Short Palmar Flap) — best for all the 
fingers, not including the thumb. 

General Indications. — Traumatism and infection. 



AMPUTATION OF A FINGER. IN GENERAL, WITH PART OF ITS 

METACARPAL, 

BY RACKET METHOD. 

Description. — The finger is removed as one continuous whole at the 
line of section of the metacarpal. 

Position. — Same as for amputation through last phalanx (page 327). 

Landmarks. — Outline of dorsal aspect of metacarpal; carpo-metacarpal 
joint; webs of fingers. 

Incision. — Begins over dorsum of metacarpal, a short distance above 
the point at which the bone is to be sawed — passes thence downward over 
the middle of the dorsal aspect until the neck of the metacarpal is reached 
— whence the median line diverges into two limbs, each limb passing down 
the dorso-lateral aspect of the finger to just below the junction of the web and 
finger — whence each limb crosses immediately in front of the digito-palmar 
crease to meet in the center of the palmar aspect of the finger (Fig. 320, L). 



342 AMPUTATIONS. 

Operation.— This incision is rleepened to the bone on the line of the 
retracted skin. The extensor tendons are divided near the upper end of 
the vertical incision. The sides of the shaft of the metacarpal are carefully 
cleared, hugging the bone in the process. The region of the metacarpo- 
phalangeal joint is also freed and the flexor tendons divided near the neck 
of the metacarpal, while the finger is forcibly extended. The shaft of the 
metacarpal is further cleared up to the saw-line, the finger being held in 
extreme extension. The Gigli or chain saw is now passed beneath the meta- 
carpal, while the soft parts are held out of the way, and the bone sawed so 
as to bevel it from below upward and toward the dorsum. The digital 
arteries are divided and are to be tied. The synovial sheath of the flexor 
tendons should be closed with gut sutures. The wound is sutured in a single 
median line upon the dorsal aspect. 



AMPUTATION OF THUMB WITH PART OF ITS METACARPAL 

BY RACKET METHOD. 

Description — Position — Landmarks. — As for amputation of a finger 
with part of its metacarpal (page 341). 

Incision. — As in disarticulation of thumb with its entire metacarpal, by 
the racket method (page 345) — except that the queue of the incision only 
extends up to a little above the sawdine. 

Operation. — As for amputation of a finger with part of its metacarpal 
(page 341). The metacarpal should be beveled from above downward and 
inward. 

AMPUTATION OF LITTLE FINGER WITH PART OF ITS METACARPAL 

BY RACKET METHOD. 

Description — Position — Landmarks. — As for amputation of a finger 
with part of its metacarpal (page 341). 

Incision. — As in disarticulation of little finger with its entire metacarpal, 
by the racket method (page 344) — except that the queue of incision begins 
just above sectiondine of bone. 

Operation. — As for amputation of a finger with part of its metacarpal, 
by the racket method. The metacarpal should be beveled from above 
downward and toward the radial side. 



AMPUTATION OF TWO CONTIGUOUS INSIDE FINGERS WITH PART 
OF THEIR METACARPALS 

BY RACKET METHOD. 

Similar, practically, to the disarticulation of two contiguous inside fingers 
with their entire metacarpals, by the racket method (page 346). 



AMPUTATION OF THREE INSIDE FINGERS WITH PARTS OF 
THEIR METACARPALS 

BY RACKET METHOD. 

See the disarticulation of the three innermost fingers with their entire 
metacarpals by the racket method (page 346). 



DISARTICULATION OF FINGERS WITH ENTIRE METACARPALS. 343 

AMPUTATION OF THREE INNERMOST FINGERS WITH PARTS OF 
THEIR METACARPALS 

BY EQUAL DORSAL AND PALMAR FLAPS. 

See the disarticulation of the three innermost fingers with their entire 
metacarpals, by the method of equal dorsal and palmar flaps (page 346) . 

AMPUTATION OF ALL THE FINGERS (EXCLUDING THE THUMB), 
WITH PARTS OF THEIR METACARPALS, 

BY ANTERIOR ELLIPSE. 

See the corresponding disarticulation of all the fingers, exclusive of the 
thumb, with their entire metacarpals, bv an anterior ellipse (or short palmar 
flap, as it is sometimes called) (page 348). 




Fig. 322. — Showing the Relations or the Various Metacarpal to the Correspond" 
tng Carpal Bones, as Guides in Disarticulating the Metacarpals from the Carpals 
and the Adjacent Metacarpals. 



DISARTICULATION OF FINGERS, IN GENERAL, WITH THEIR ENTIRE 

METACARPALS. 

Methods. — Racket Method — best for the fingers in general, including 
thumb, index, and little fingers — and also used for the two or three inside 
fingers. Equal Dorsal and Palmar Flaps — best for three innermost fingers. 
Anterior Ellipse (Short Palmar Flap) — best for all the fingers, exclusive of 
thumb — and also best for all the fingers including thumb. Palmar Flaps — ■ 
sometimes used for the thumb, but inferior to the racket. Circular Method 
— sometimes used for all the fingers, with or without the thumb. 

Comment. — Preservation of the carpus is desirable, especially if the 
flexor and extensor tendons are so sutured into the wound that considerable 
range of movement may be secured for the stump wielding the artificial 
limb. Fig. 322 shows the intercarpal and carpo-metacarpal joints. 



344 



AMPUTATIONS. 



DISARTICULATION OF AN INNER FINGER WITH ITS METACARPAL 

BY RACKET INCISION. 

Description. — The finger is removed as one continuous whole at the 
carpometacarpal articulation. 

Position. — As for amputation through the last phalanx (page 327). 

Landmarks. — Outline of dorsal aspect of carpo-metacarpal articulation, 
and metacarpal bone. 

Incision — Begins just above the carpo-metacarpal joint — passes down 
the median dorsal aspect of the metacarpal until its neck is reached — thence 
diverges into two limbs, each limb running over the dorso-lateral aspect of 
the finger to just below the junction of the web and finger — whence each 
limb crosses the digito-palmar crease to meet in the center of the palmar 
aspect of the finger. If necessary for the purpose of aiding disarticulation 
at the carpo-metacarpal joint, a short transverse incision may be made at a 
right angle to the upper end of the queue (Fig. 320, K). 

Operation. — This incision is now deepened on a line of the retracted 
skin and fascia. The shaft of the metacarpal and the metacarpophalangeal 
joint are carefully cleared, hugging the bones as closely as possible, while 
an assistant keeps the finger in the position of extreme extension. The extensor 
tendons are divided as near the upper limit of the queue as possible — the 
flexor tendons near the neck of the metacarpal. The sides of the metacarpal 
are now bared up toward the carpo-metacarpal articulation, using especial 
care in the palmar region. The ligaments of the intermetacarpal joints 
and carpo-metacarpal joints are divided by carefully thrusting a knife between 
the sides of the bases of the metacarpals and between the metacarpals and 
the carpal bones, working from the dorsum of the hand. The disarticulation 
is completed by forcibly turning back the finger upon the dorsum of the 
hand, completing, with the knife, the division of any undivided ligaments, 
insertions of tendons, or palmar structures. The synovial sheaths of the 
flexor tendons should be sutured with catgut, if possible. Tie the two digital 
arteries — and suture the wound in a single median line upon its dorsal aspect. 



DISARTICULATION OF INDEX-FINGER WITH ITS METACARPAL 

BY RACKET INCISION. 

Description. — The steps of this operation are practically the same as 
for the corresponding operation upon an inner finger. The incision is in 
the mid-dorsal line. The addition of a short transverse incision at a right 
angle to the upper end of the queue is especially advisable here, owing to 
the width of the base of the second metacarpal. The outer (radial) of the 
diverging limbs below should follow the dorsal aspect a little further down 
before sweeping over the lateral aspect than does the inner (ulnar) limb, in 
order to bring the scar more out of the way of pressure. The index should 
be extended and abducted in clearing and disarticulating. Tie the digital, 
radialis indicis, and dorsalis indicis arteries — and suture the wound in a ver- 
tical dorsal line. 



DISARTICULATION OF LITTLE FINGER WITH ITS METACARPAL 

BY RACKET INCISION. 

Description. — The steps of the operation are essentially similar to those 
for the removal of an inner finger with its metacarpal by the racket incision. 
It is better to place the incision in the mid-dorsal aspect than toward the 



DISARTICULATION OF THUMB WITH ITS METACARPAL. 345 

inner (ulnar) side of the metacarpal, as objects less easily press such a scar. 
At the upper extremity of the queue a short transverse incision may be added, 
not crossing the upper end of the queue (as in the case of the inner fingers), 
but running from the upper end of the queue at a right angle toward the 
ulnar aspect of the hand, over the carpo-metacarpal joint — to allow of readier 
disarticulation. The inner (ulnar) of the diverging limbs below should 
follow the dorsal aspect a little further down before sweeping over the lateral 
border than does the outer (radial) limb — in order to bring the scar more 
out of the way of pressure. The little finger should be extended and ab- 
ducted (from the median line of the hand) in clearing and disarticulation. 
Carefully close the large synovial sac of the little finger, if opened. Preserve 
the hypothenar muscles as far as possible and suture into the wound. Suture 
the wound in a single dorsal line (Fig. 320, J). 



DISARTICULATION OF THUMB WITH ITS METACARPAL 

BY RACKET INCISIOX. 

Description. — Removal of the thumb, together with its metacarpal, at 
the carpo-metacarpal joint. 

Position. — Same as for the fingers, except that the hand is held midway 
between pronation and supination. 

Landmarks. — Outline of the dorsal aspect of the metacarpal, and the 
carpo-metacarpal joint. 

Incision. — Begins just above the carpo-metacarpal joint-line, in the 
mid-dorsal aspect of the metacarpal — passing into the "snuff-box," if at all, 
with great care and, at first, very superficially, on account of the radial artery. 
The incision then passes down the center of the dorsum of the thumb to the 
neck of the metacarpal — and here divides into the two limbs of an oval, 
which part to encircle the head of the metacarpal, crossing the palmar aspect 
of the thumb on a level with the free edge of the web — the outer (radial) of the 
diverging limbs following the dorsal aspect a little further down before sweep- 
ing over the lateral aspect than does the inner (ulnar) limb (Fig. 320, N). 

Operation. — This incision is deepened on the line of the retracted skin 
and fascia. The extensor tendons of the first and second phalanges are 
cut as long as possible, so as to be sutured into the wound. The dorsum 
and sides of the metacarpal are cleared of soft parts, hugging the bone. The 
thumb is extended and abducted and the muscles attached to the base of 
the first phalanx are divided near the sesamoid bones, preserving the thenar 
muscles as far as possible. The palmar aspect of the metacarpal is cleared 
while an assistant rotates the thumb from side to side, working as near the 
bone as possible. The flexor longus pollicis tendon is divided low down, so 
that it may be sutured into the wound. Disarticulation is accomplished 
by severing the binding ligaments and the extensor ossis metacarpi pollicis, 
while the thumb is flexed into the palm — opening the joint from the dorsum, 
the thumb being then rotated in different directions to complete the dis- 
articulation. Suture the sheath of the flexor tendon. Tie the arteria princeps 
pollicis, or its two branches, and the dorsalis pollicis. Quilt the muscles, 
suturing the flexor, extensor, and thenar tendons and muscles into the wound. 
The cicatrix will run in a dorsal median line. 



346 AMPUTATIONS. 



DISARTICULATION OF TWO CONTIGUOUS INSIDE FINGERS WITH 
THEIR METACARPALS 

BY RACKET INCISION. 

Description. — The operation is the same, in principle, as that for the 
removal of a single finger and its metacarpal. A vertical incision begins 
just above the carpo-metacarpal joint-line and between the bases of the two 
contiguous metacarpals — passes down the back of the hand midway between 
the two metacarpals for about one-half of their length — then divides into 
the two limbs of an oval, or racket — the radial limb passing to the radial side 
of the outer of the two fingers to be removed — the ulnar limb to the ulnar 
side of the inner of the two fingers to be removed — to the junction of the 
fingers and webs — thence both limbs cross and meet beneath the fingers 
in the digito-palmar crease. The incision is deepened — the metacarpals 
cleared — the tendons cut long — disarticulation accomplished — and the opera- 
tion completed just as in the disarticulation of a single finger and its meta- 
carpal. The flexor and extensor tendons are to be sutured into the wound. 
(Fig. 320, M.) 

DISARTICULATION OF THREE INSIDE FINGERS WITH THEIR META- 
CARPALS 

BY RACKET INCISION. 

Description. — Same, in the main, as the disarticulation of any two 
contiguous inside fingers with their metacarpals — except that the vertical 
incision begins just above the carpo-metacarpal joint line, over the center 
of the base of the central one of the three metacarpals — passes down this 
metacarpal for about one-third of its length — and thence diverges, the radial 
limb to the radial side of the outer finger, and the ulnar limb to the ulnar 
side of the inner finger — both limbs passing to the junction of the fingers 
with the webs — and thence crossing and meeting in the digito-palmar crease 
beneath the central finger. The operation is completed as in the last — three 
fingers and their metacarpals being removed instead of two. 



DISARTICULATION OF THREE INNERMOST FINGERS WITH THEIR 

METACARPALS 

BY EQUAL DORSAL AND PALMAR FLAPS. 

Description. — Corresponding incisions are made upon palmar and 
dorsal aspects of the hand, furnishing symmetrical flaps. 

Position. — As in operations upon the fingers (page 327). 

Landmarks. — Carpo-metacarpal articulations of third, fourth, and fifth 
metacarpals; middle palmar crease. 

Incision. — (1) Palmar incision — begins just below the base of the fifth 
metacarpal — passes downward and outward across the palm, parallel with 
but just below the middle palmar crease, until opposite the center of the 
ring-finger or just beyond — and is thence directed to the junction of the 
outer side of the middle finger and web. (2) Dorsal incision — corre- 
sponds with the palmar incision (Fig. 323, A). 

Operation. — The above incisions are deepened on the line of the retracted 
skin and fascia. The metacarpal bones are bared to their joint-lines, which 
is more easilv done in the case of the fourth and fifth, the third being exposed 



DISARTICULATIONS OF FINGERS WITH THEIR METACARPALS. 



347 



by upward and outward retraction of the soft parts. The nerves are cut 
as near the line of disarticulation as possible. The flexor and extensor 
tendons are cut long, so as to be sutured into the wound. Care is taken 
not to wound the deep arch. Tie the interosseous branches of the deep arch, 
and the palmar digital branches of the superficial arch, or the arch itself, if 
wounded. Suture the synovial sheaths where opened. The muscles of the 
hypothenar eminence are left in the palmar flap as far as possible and are 
quilted to the fascia of the dorsal region, where there are no muscles. The 










Fig. 323.— Amputations about the Hand : — A, Disarticulation of three inner fingers, with their 
metacarpals, by equal dorsal and palmar flaps; B. Disarticulation of all the fingers, except thumb, 
with their metacarpals, by anterior ellipse; C, Disarticulation at wrist-joint, by circular method. 
(Dorsal view.) 



flexor and extensor tendons are also sutured into the wound. The dorsal and 
palmar flaps are united by suture extending along the ulnar side of the hand. 
Comment. — In the unusual cases where this operation is done, injury 
has generally been the cause, and its extent upon the dorsum and palm will 
determine the outline of the coverings. Where both are equally involved 
the above coverings will have to be taken — but if the predominant covering 
could be gotten from the palm, so as to make a larger palmar and smaller 
dorsal flap, the scar would lie on the dorsal aspect and be out of the way of 
pressure, which would be preferable. 



348 AMPUTATIONS. 

DISARTICULATION OF ALL FINGERS, EXCLUDING THUMB, WITH 
THEIR METACARPALS 

PA' ANTERIOR ELLIPSE. 

Description. — This is, practically, a palmar covering, whose convex 
anterior border fits into the concave wound on the dorsum of the hand. It 
is sometimes called the short palmar flap method. 

Position. — As in the amputations upon the fingers in general (page 327). 

Landmarks. — Base of fifth metacarpal (marking the point at which the 
ellipse crosses the ulnar border of the hand); point midway between the 
central crease of the hand and the level of the outstretched thumb (marking 
the point at which the ellipse crosses the radial border of the hand); the 
carpometacarpal joint-line. 

Incisions. — Palmar incision — passes between the two above points, with 
a downward convexity, whose lowest part reaches below the middle of the 
metacarpals. Dorsal incision — also passes between the same two points, 
with an upward convexity, whose highest part corresponds with the bases 
of the two inner metacarpals (Fig. 323, B). 

Operation. — These incisions are deepened to the bone. The flexor 
and extensor tendons are cut long. The soft parts are cleared up to the 
carpo-metacarpal joint-line — the metacarpals are disarticulated from the 
carpals, and the second metacarpal from the first metacarpal, cutting the 
dorsal ligaments by flexing and the palmar ligaments by extending the hand. 
Tie the palmar digital, palmar interosseous, dorsalis indicis, radialis indicis, 
and palmar arches, if severed. Close the flexor sheaths — suture the flexor 
and extensor tendons into the wound — and suture the convex palmar flap 
to the concave dorsal wound. 



DISARTICULATION OF FINGERS AND THUMB AT CARPO-META- 
CARPAL ARTICULATION 

BY PALMAR FLAP. 

Description. — Same, in principle, as the disarticulation of the hand at 
the wrist-joint (page 352) — except that the upper limits of the flap extend 
only to the ulnar margin of the unciform-metacarpal articulation, on the 
one side, and the radial margin of the trapezio-metacarpal articulation, on 
the other side — the lower limit crossing the necks of the metacarpals. 



SURGICAL ANATOMY OF THE WRIST- JOINT. 

Bones. — Radius; ulna; first row of carpal bones (scaphoid, semilunar, 
cuneiform, pisiform). 

Ligaments. — Anterior radiocarpal; posterior radio-carpal; external 
lateral; internal lateral; and synovial membrane. 

Movements. — Flexion; — accomplished by flexor carpi radialis; flexor 
carpi ulnaris; palmaris longus. Extension; — by extensor carpi radialis 
longior; extensor carpi radialis brevior; extensor carpi ulnaris. Adduction; — 
by flexor carpi ulnaris; extensor carpi ulnaris. Abduction; — by extensor ossis 
metacarpi pollicis; extensores brevior et longior pollicis; extensores carpi 
radialis longior et brevior; flexor carpi radialis. 

Muscles and Tendons in Neighborhood of Wrist-joint.— (a) Ante- 
riorly; — flexor carpi radialis; palmaris longus; flexor carpi ulnaris; flexor 



SURFACE FORM AND LANDMARKS OF THE WRIST-JOINT. 349 

sublimis digitorum; tlcxor profundus digitorum; flexor longus pollicis. (b) 
Posteriorly; — extensores carpi radialis longior et brevior; extensor communis 
digitorum; extensor indicis; extensor minimi digiti; extensor carpi ulnaris. (c) 
Radial Aspect; — supinator longus; extensor ossis metacarpi pollicis; extensor 
brevis (primi internodii) pollicis; extensor longus (secundi internodii) pollicis. 

Arteries in Neighborhood of Wrist-joint. — Radial, with its anterior 
carpal, superficialis volae, posterior carpal and metacarpal (first dorsal inter- 
osseous). Ulnar, with its anterior carpal, posterior carpal, carpal branch 
of anterior interosseous, posterior termination of anterior interosseous. Carpal 
recurrent branch from deep arch. 

Veins in Neighborhood of Wrist-joint. — Superficial — anterior ulnar; 
posterior ulnar; radial; median. Deep — two vena 1 comites accompany each 
of the above arteries. 

Nerves in Neighborhood of Wrist-joint. — Superficial — anterior and 
posterior branches of musculocutaneous; anterior and posterior branches 
of internal cutaneous; palmar cutaneous branch of median; palmar cutaneous 
branch of ulnar; cutaneous branch of ulnar communicating with anterior 
branch of internal cutaneous (frequently absent) ; dorsal cutaneous branch 
of ulnar; palmar cutaneous branch of radial; dorsal division of radial. 
Deep; — median; ulnar; termination of interosseous. 



SURFACE FORM AND LANDMARKS OF THE WRIST-JOINT. 

Articulation of the wrist-joint is on a level with the apex of the styloid 
process of the ulna, which is the key to the joint. To find the joint-line of 
the wrist, draw a straight line connecting the radial and ulnar styloid processes 
— then draw a curved line between the same points, with the highest part of 
the convexity 1.3 cm. (J inch) above the straight line — this curved line will 
represent the dome-shaped articular line. The ulnar styloid process is more 
distinct in pronation — that of radial in supination. 

Two or three skin-folds generally cross the palmar surface of the wrist 
transversely — the lowest fairly represents the upper border of the anterior 
annular ligament — and is about 1.3 to 2 cm. (^ to f inch) below the arch 
of the wrist-joint. 

All the muscles mentioned above under Surgical Anatomy can generally 
be felt and recognized about the wrist-joint — except the flexor profundus 
digitorum and flexor longus pollicis, of the anterior group; the extensor 
carpi ulnaris, of the posterior group; and the supinator longus, of the radial 
group. 

Bony prominences of the tubercle of the scaphoid and ridge of the trape- 
zium are generally to be felt on the anterior aspect of the radial side of the 
wrist — and those of the pisiform and unciform process of the unciform, on 
the ulnar side. 

The lower end of the diaphysis of the ulna just comes to the radio-ulnar 
joint. The lower end of the diaphysis of the radius comes within the synovial 
membrane. 

The tendon of the extensor longus (secundi internodii) pollicis marks 
the center of the lower end of the radius — and indicates the interval between 
the scaphoid and semilunar. 

The ulnar artery, with the ulnar nerve to the ulnar side, lies on the anterior 
annular ligament, to the radial side of the pisiform and to the ulnar side of 
the hook of the unciform (in the groove between them). The deep branch 
of the ulnar artery arises directly below the pisiform. 



350 AMPUTATIONS. 

The radial artery passes under the extensor tendons of the thumb, upon 
the external lateral ligament, winding over the outer side of the carpus from 
a point just below and internal to the styloid process of the radius to the 
base of the first interosseous space. 

The superficial palmar arch is on a line with the lower border of the 
outstretched thumb — and the deep arch is 1.3 cm. (h inch) higher. 



GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT THE 

WRIST-JOINT. 

Disarticulation at the wrist-joint is preferable to amputation through 
the forearm, as pronation and supination are usually retained, and the stump 
is better adapted to an artificial limb. 

Avoid injuring the radio-ulnar articulation — which is adjacent to, but 
not a part of, the wrist-joint. 

The styloid processes of the radius and ulna should not be removed, 
especially that of the radius, owing to the attachment of the supinator longus. 

Disarticulation of the joint is more easily done from the dorsum. 

The pisiform bone is often unconsciously removed with the flap, and it 
is convenient to so remove it and subsequently to dissect it out. 

The best covering for the joint is from the palm, but the nature of the 
condition for which the operation is done will generally determine from 
which aspect the covering can be gotten. Care must be exercised to cover 
the prominent radial styloid process. In approximating the thick palmar 
to the thin dorsal skin, the sutures are to be securely tied and left amply long. 
Drainage is indicated for twenty-four or thirty-six hours. The stump should 
be placed upon a splint which will steady the part and prevent pronation 
and supination, in a position midway between pronation and supination. 

The lower epiphyses of the radius and ulna join the bones about the 
twentieth year. 



DISARTICULATION AT THE WRIST- JOINT, IN GENERAL. 

Best Methods. — Anterior Ellipse; Palmar Flap; External lateral, or 
radial, Flap (Dubrueil's Method). 

Other Methods. — Modified Circular; Circular; Equal Palmar and 
Dorsal Flaps; Dorsal Flap. 

Comment. — Anterior ellipse method forms the best covering, and amounts 
to a palmar flap. Palmar flap — rather bulky and unyielding and less ad- 
justable. External flap — a good substantial covering, and especially adapted 
to cases in which the palmar covering is not available. Circular method — 
forms a scanty covering. Dorsal flap — warrantable when the palmar and 
external coverings are unavailable, but consists only of skin and tendons. 

General Indications. — Bad crushes of hand; malignant disease; chronic 
disease of bones or joints of hand 



DISARTICULATION AT THE WRIST-JOINT. 



DISARTICULATION AT THE WRIST- JOINT 

BY ANTERIOR ELLIPSE. 

Description. — The covering raised is, practically, an anterior flap. The 
idea of the ellipse is appreciated after marking the outline, as given below, 
and then viewing it from the radial or ulnar aspect of the hand. 




Fig. 324. — Disarticulation ai the Wrist-joint by the Anterior Elliptical Method. 

(Palmar view.) 
Fig. 325.— Disarticulation at the Wrist-joint by the Palmar Flap Method. (Palmar 

view.) 

Position. — Patient on back, forearm abducted horizontally; hand pro- 
nated or supinated, as indicated by the stage of the operation. Surgeon sits 
or stands, facing the patient's hand. An assistant steadies the limb from 
above, and holds the parts out of the way. 

Landmarks. — Line of the wrist- joint; pisiform; base of fifth metacarpal; 
carpo-metacarpal joint of the thumb. 

Incision. — Highest point of the ellipse is upon the dorsum, 1.3 cm. (| 
inch) below the line of the wrist-joint, and on a line with the middle finger. 
Lowest point of the ellipse is upon the palm, 6.3 cm. {t\ inches) below the 
line of the wrist-joint, and on a line with the middle finger. The inner 
portion of the ellipse crosses the ulnar border of the hand between the pisiform 
bone and base of the fifth metacarpal. The outer portion of the ellipse 



352 AMPUTATIONS. 

crosses the radial border of the hand at the carpo-metacarpal joint-line of 
the thumb. The entire incision has, therefore, a downward convexity upon 
the palm and an upward convexity upon the dorsum, and passes through 
the four above-mentioned points (Fig. 324, A). 

Operation. — Supinating the hand while incising the palm, and pronating 
it while making the dorsal incisions, this entire ellipse, which has been made 
through the skin and fascia at first, is now deepened throughout. The 
dorsal integuments are first dissected to the joint-line. The hand is flexed 
and the extensor tendons, posterior ligament, and lateral ligaments are cut 
and the joint opened — and then the anterior ligaments. First one and then 
the other lateral border of the hand is made to present and the lateral parts 
of the ellipse carried to the bones. The knife is then carried between the 
flexor tendons and the carpus, from above and within, and made to clear 
out the hollow of the carpus in the act of cutting its way obliquely from within 
downward and outward, to the margin of the palmar incision through the 
skin — and the hand thus severed from the arm. All loose tendons and 
nerves are to be cut. The following arteries are to be tied; radial, ulnar 
(below the deep branch), deep branch of the ulnar, superficialis volae. The 
deep palmar arch and part of the superficial palmar arch are removed with 
the hand. The convex palmar flap is sutured into the concave wound at 
the back of the wrist. 

Comment. — The palmar covering can be entirely freed up to the joint- 
line before disarticulating. 



DISARTICULATION AT THE WRIST 

BY PALMAR FLAP. 

Description. — The flap is U-shaped, and raised entirely from the palm. 

Position. — As in the disarticulation by an anterior ellipse (page 304). 

Landmarks. — Styloid process of radius; styloid process of ulna; middle 
of metacarpus. 

Incision. — Palmar incision — radial limb of the U begins 1.3 cm. (^ inch) 
below the radial styloid process and is directed downward along the radial 
border of the index. Ulnar limb of the U begins 1.3 cm. (J? inch) below the 
ulnar styloid process and is directed downward along the ulnar border of 
the little finger. These limbs are bluntly rounded at their lower ends and 
pass transversely toward each other so as to meet just above the center of 
the metacarpus. Dorsal incision — crosses the carpus in a straight line, or, 
better, with slightly downward convexity, between the two upper ends of the 
palmar incision (Fig. 325). 

Operation. — With the hand in supination and extension, the palmar 
incision is deepened to the flexor tendons, the thenar and hypothenar muscles 
being cut through to that extent — and the palmar flap then dissected up to 
the joint-line, raising the flap from the bony prominences in the palm. With 
the hand now in pronation and the skin of the wrist drawn upward, the dorsal 
incision is deepened and the integuments dissected up to the joint-line, when 
the extensor tendons, posterior ligament, and lateral ligaments are severed 
and disarticulation accomplished. The flexor tendons and surrounding tis- 
sues on the palmar surface are now severed, while on the stretch, by dividing 
the anterior ligament from within the disarticulated joint and then cutting 
the flexor tendons from the dorsal toward the palmar aspect, on a line with 



SURGICAL ANATOMY OF THE FOREARM. 353 

the retracted palmar (lap. The same arteries are to be tied as in the ellip- 
tical method, the deep arch and loops of the superficial arch coming away 
with the hand. 



DISARTICULATION AT THE WRIST- JOINT 

BY EXTERNAL LATERAL, OR RADIAL FLAP — DUBRUEIL'S METHOD. 

Description. — A saddle-shaped flap of skin and muscles is raised from 
the metacarpal region of the thumb, and approximated to the disarticulated 
ends of the radius and ulna. 

Position. — As in disarticulation by the elliptical method (page 351). 

Landmarks. — Wrist-joint; first metacarpal. 

Incision. — Flap-incision — begins on back of wrist, about 6 mm. (j inch) 
below the wrist-joint line, and at the junction of the outer and middle thirds 
of that line — passes thence downward upon the dorsal aspect of the thumb — 
thence rounds outward to cross the first metacarpal transversely about its 
middle (remaining, up to the point of rounding outward, as far from the 
outer border of the hand as at the beginning). The incision now passes 
upward correspondingly on the inner aspect of the thumb, following the 
inner part of the thenar eminence to a point about 6 mm. (| inch) below the 
wrist-joint line, at the junction of the outer and middle thirds of that line 
on the palmar surface. Disarticulating-incision — the two upper ends of this 
flap are connected by a transverse incision passing directly around the inner 
aspect of the wrist-joint (Fig, 320, P, P). 

Operation. — The thenar incision, forming the flap, is deepened — the 
soft parts are dissected from the metacarpal, and as much of the thenar 
muscles as possible is taken. The soft parts upon the inner aspect of the 
wrist are divided to the bone by the circular incision on a level with the base 
of the flap. Disarticulation is accomplished from the dorsal and inner 
aspect, toward the palmar and outer. The following arteries are to be tied: 
superficial and deep palmar arches, dorsalis and radialis indicis and ulnar. 
The tendons and nerves are treated as in the preceding operations upon the 
wrist. The external or thenar flap is now brought transversely across the 
articular ends of the radius and ulna, and sutured to the circularly divided 
parts. 



SURGICAL ANATOMY OF THE FOREARM. 

Bones. — Radius; ulna. 

Articulations and Ligaments. — (a) Superior Radio-ulnar Articulation; 
— orbicular ligament; synovial membrane, (b) Middle Radio-ulnar Articu- 
lation; — oblique (round) ligament; interosseous membrane. (c) Inferior 
Radio-ulnar Articulation; — anterior radio-ulnar ligament; posterior radio- 
ulnar ligament; interarticular (triangular) fibro-cartilage; synovial mem- 
brane, (d) Elbow-joint (page 359). (e) Wrist-joint (page 348). 

Muscles of the Forearm. — (a) Anterior radio-ulnar region : — (i) 
More Superficial Muscles; — pronator radii teres; flexor carpi radialis; palmaris 
longus; flexor carpi ulnaris; flexor sublimis digitorum. (2) Deeper Muscles; 
— flexor profundus digitorum; flexor longus pollicis; pronator quadratus. 
(b) Radial region: — supinator longus; extensor carpi radialis longior; ex- 
tensor carpi radialis brevior. (c) Posterior radio-ulnar region:— (1) 

2 3 



354 AMPUTATIONS. 

More Superficial Muscles; — extensor communis digitorum; extensor minimi 
digiti; extensor carpi ulnaris; anconeus. (2) Deeper Muscles; — supinator 
brevis; extensor ossis metacarpi pollicis; extensor brevis (primi internodii) 
pollicis; extensor longus (secundi internodii) pollicis; extensor indicis. 

Arteries of the Forearm. — Radial, with radial recurrent; muscular; 
anterior carpal; superficialis volar, posterior carpal branches. Ulnar, with 
anterior ulnar recurrent; posterior ulnar recurrent; common interosseous; 
anterior interosseous; posterior interosseous; muscular; anterior carpal; 
posterior carpal branches. 

Veins of Forearm. — Superficial — median; median cephalic; median 
basilic; deep median; radial cephalic; cephalic; anterior ulnar; posterior 
ulnar; common ulnar; basilic. Deep — two venae comites accompanying each 
of above arteries. 

Nerves of Forearm. — Superficial; — musculocutaneous; internal cutane- 
ous; external cutaneous branch of musculospiral; cutaneous branch of ulnar; 
dorsal cutaneous branch of ulnar; cutaneous branches of radial. Deep; — 
ulnar and its muscular branches; median and its muscular branches; muscular 
branches of musculospiral; radial branch of musculospiral; posterior inter- 
osseous branch of musculospiral. The cross-sections of the forearm are shown 
in Figs. 32, 34, and 327. 



SURFACE FORM AND LANDMARKS OF THE FOREARM. 

Olecranon and posterior border of upper part of ulna are subcutaneous 
— and the entire shaft is to be felt down to the styloid process, passing from 
the center of the forearm above to the ulnar side of the wrist below, and lying 
between the flexor and extensor carpi ulnaris. The ulnar styloid process is 
best felt with the forearm midway between flexion and extension, being con- 
tinuous with the posterior subcutaneous border of the bone. 

Head of the radius is felt just below and a little in front of the posterior 
surface of the external condyle, revolving in the orbicular ligament and lesser 
sigmoid cavity — marked by a dimple in the skin posteriorly, best seen when 
the arm is extended. The lower half of the radius can be outlined, though 
not subcutaneous — the outer aspect of the lower part alone being subcutaneous, 
and ending in the radial styloid process. The radius is deeply covered above 
and superficially covered below. Opposite a point in the forearm where 
one bone is most slender, the opposite bone is most substantial — both being 
about equal in the middle. The radius and ulna are everywhere nearer the 
posterior than anterior aspect of the forearm, and increasingly so above. 
They are nearest each other in complete pronation and furthest in complete 
supination. 

Flexor and pronator muscles form the muscular elevation upon the inner 
side of the elbow and forearm — the extensor and supinator muscles forming 
a corresponding elevation upon the outer and posterior side of the elbow 
and forearm. These two groups diverge above toward the condyles of the 
humerus and converge below toward the center of the forearm — the supinator 
longus forming the outer boundary and the pronator radii teres the inner 
boundary of the triangular space at the bend of the elbow. Of the muscles 
of the internal group, the pronator radii teres, flexor carpi radialis, palmaris 
longus, flexor carpi ulnaris, alone influence surface form, the remainder being 
unrecognizable. The external group of muscles divides into two longitudinal 



SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT FOREARM. 355 

eminences, diverging from each other, with a triangular interval between 
them: — the outer, consisting of the supinator longus, extensor carpi radialis 
longior and brevis, descending from the outer condyloid ridge toward the 
radial styloid process; — the other, more posterior, consisting of the extensor 
communis digitorum, extensor minimi digiti, extensor carpi ulnaris, descend- 
ing from the external condyle, separated above from the anconeus by a furrow, 
and below from the pronator-flexor mass by the ulnar furrow. In the tri- 
angular interval between these two groups the extensor ossis metacarpi 
pollicis, extensor brevis pollicis, extensor longus pollicis, and extensor indicis 
pass downward. The anconeus forms a slight prominence external to the 
subcutaneous posterior surface of the olecranon. 

In the muscular, the transverse is much greater than the antero-posterior 
diameter of the forearm — and the downward tapering is marked. In the 
non-muscular, the forearm is more rounded and the tapering is less. Above, 
the muscles are found chiefly at the sides and in front; — below, more equally 
along the anterior and posterior aspects — hence flap amputations are 
more adapted to the upper and circular amputations to the lower part of 
the forearm. 

The three chief pronators of the forearm are, the pronator radii teres, 
pronator quadratus, and flexor carpi radialis. The three chief supinators 
are, the supinator longus, supinator brevis, and biceps. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE FOREARM. 

For the purposes of amputation, the forearm may be divided into two 
natural regions, a lower one-third and an upper two-thirds — the former 
being characterized by an almost even contour of similar dimensions through- 
out — the latter, especially in the muscular, by its rapidly increasing measure- 
ments up to from 2.5 to 5 cm. (1 to 2 inches) below the elbow, and with a 
slight decrease thence to the elbow-joint. Therefore, on this account, and 
because of the grouping of the muscles, amputation-methods are described 
as applicable to "the lower third" and "the upper two-thirds." (In this 
connection, see the last paragraph from the bottom, in the above section.) 

The general type of amputation most suitable for the lower third of the 
forearm is the circular method — and the general type most suitable for the 
upper two-thirds is the flap method. 

Saving of the smallest part of the forearm, with its movement, is preferable 
to disarticulation at the elbow. 

If possible, the bones should be sawed below the insertion of the pronator 
radii teres, otherwise the radius will become supinated and rotatory move- 
ments lost. 

Owing to the tendency of the bones to project through the angles of the 
flaps, the flaps at their bases and their lower ends should be made fully long. 

In cutting by transfixion the interosseous membrane is apt to be pierced. 

A terminal cicatrix is here desirable, as best adapted to an artificial limb. 

The stump should be dressed with the forearm midway between pronation 
and supination, and the elbow steadied by a right-angled splint. 



356 



AMPUTATIONS. 



AMPUTATION OF THE FOREARM, IN GENERAL. 

Best Methods. — Modified Circular — 
for the lower third. Equal Anterior and 
Posterior Flaps— for the upper two-thirds 

Other Methods. — Long Anterior Flap 
— where the posterior tissues are defi- 
cient. Long Posterior Flap — where the 
anterior tissues are deficient. Long An- 
terior and Short Posterior Flap. Rec- 
tangular Flaps (Teale's method). Ex- 
ternal Lateral Flap — where the internal 
tissues are deficient. Equilateral Skin- 
flaps. Circular Skin-flap. Circular. 

General Indications. — Injury; tuber- 
cular disease of wrist; malignancy. 

AMPUTATION OF LOWER THIRD OF 
FOREARM 

BY MODIFIED CIRCULAR METHOD. 

Description. — Two short flaps of 
skin and fascia are turned back and 
the muscles are then circularly divided at 
the level of the retracted skin-and-fascia 
flaps. 

Position. — Patient supine, near edge 
of table, with upper limb abducted to a 
right angle — and held by an assistant in 
supination during anterior incisions, and 
in pronation, or vertically, during pos- 
terior incisions. Surgeon to outer side of 
right limbs and inner side of left. 
Landmarks. — Saw-line. 
Incision. — The total covering is to be 
i^ diameters of the forearm at the saw- 
line. The anterior and posterior aspects will each furnish three-fourths 
of a diameter. One-half of this three-fourths diameter length will be of 
skin and fascia alone, on each side — the remaining half of skin, fascia, 
and muscle. Therefore a point below the saw-line equal to three-fourths 
of a diameter at the saw-line will mark the lowest limit from which the covering 
is to be provided. Two small flaps are incised, each having a base equal 
to a half-circumference, and a length equal to half (the lower half) of the 
distance between the saw-line and the lowest limit of the skin incision. These 
flaps will be bluntly rounded at their lower ends (Fig. 326, A). 

Operation. — Dissect up the integumentary flaps half-way to the saw- 
line — retract them, and, on a level with the retracted flaps, circularly divide 
the muscles to the bone. This circular incision also divides the periosteum 
and interosseous membrane. The muscles and periosteum are then retracted 
to the saw-line — and the bones divided, completing the section of the more 
movable radius first. Tie the radial, ulnar, anterior and posterior inter- 
osseous arteries. Stitch the musculo-periosteal covering over the bones. 




Fig. 326. — Amputations through 
the Forearm and at the Elbow: — ■ 
A, Through lower part of forearm by 
modified circular; B, Through upper 
forearm by equal anterior and posterior 
flaps; C, Disarticulation at elbow-joint 
by oblique circular method. 



AMPUTATION OF LOWER THIRD OF FOREARM. 357 

Quilt the muscles or tendons of the anterior to those of the posterior aspect 
of the forearm if possible. Suture the integumentary coverings in a straight 
line antero-posteriorly. 

Comment. — The preponderance of tendinous over muscular tissues here 
makes the infundibular variety of the modified circular difficult or impossible. 




Fig. 327. — Cross-section of the Middle of the Right Forearm: — A, Flexor carpi 
radialis; B, Median nerve; C, Supinator longus; D, Radial artery, veins, and nerve; E, Flexor 
longus pollicis; F, Extensor carpi radialis; G, Extensor ossis metacarpi pollicis; H, Flexor sub- 
limis digitorum; I, Flexor carpi ulnaris; J, Ulnar artery, veins, and nerve; K, Flexor profundus 
digitorum; L, Anterior interosseous vessels; M, Extensor indicis; X, Extensor carpi ulnaris; 
O, Extensor minimi digiti; P, Extensor communis digitorum. (The crods-section modified 
from Braune.) 



AMPUTATION OF LOWER THIRD OF FOREARM 

BY CIRCULAR METHOD (CUFF VARIETY). 

Description. — The cuff variety of the circular amputation is here done 
(see under Comment). A cuff of skin, circularly cut, is turned back — and 
the muscles circularly divided on a level with the reflected skin — the ends 
of the bones being covered by skin and fascia alone. 

Position. — As in the last operation. 

Landmarks. — Saw- line. 

Incision. — Circular cut, placed three-fourths of a diameter (at the saw- 
line) below the line of bone-section — thus making a total covering of i 1 
diameters, as each side may be regarded as furnishing one-half of the cover- 
ing. (For principle, see Fig. 328, A.) 

Operation. — This circular incision divides the skin and fascia, which 
are then dissected up, the forearm being vertical while the posterior dissection 
is done. This dissection and turning back of the flap is continued up to a 
distance below the saw-line which will leave space to provide a musculo- 
periosteal covering. Here, after well retracting the integumentary coverings, 
the muscles are divided circularlv to the bone, — extending the hand while 



35» 



AMPUTATIONS. 



c 



B 



the flexors are cut and flexing it while the extensors are being severed. A 
circular cut is made through the periosteum, around each bone, on a level 
with the cut muscles — the interosseous membrane is divided transversely — 

and a musculo-periosteal covering is freed 
up to the saw-line, with a periosteal 
elevator, from each bone. All soft parts 
are now retracted and the bones sawed, 
completing the section of the more mov- 
able radius first. Tie the radial, ulnar, 
anterior and posterior interosseous arter- 
ies. Cut the tendons (which are here 
especially numerous) and the nerves 
short. Suture the musculo-periosteal 
covering over the bones — and stitch the 
skin and fascia in a vertical antero-pos- 
terior or lateral direction. 

Comment. — (i) Owing to the pre- 
dominance of tendons in this locality, the 
infundibuliform variety of the circular 
method is impracticable. (2) The above 
operation is very similar to the modified 
circular method just described, which is 
generally considered better than the pres- 
ent form, in this locality. The cuff 
method, indeed, is not possible if the 
limb tapers very decidedly at the site in- 
volved. (3) A musculo-periosteal cover- 
ing is specially indicated here, as being 
the best means of guarding against a 
fusion of the cut edges of the bones and 
consequent loss of pronation and supina- 
tion. (4) As the large mass of tendons 
is difficult to cut squarely by a circular 
incision, a long, narrow knife may be 
slipped under them, and they may then 
be cut directly upward from within — or they may be divided with strong, 
sharp scissors. 




P'ig.328.— Amutations about Fore- 
arm and Elbow : — A, Through middled 
forearm, by circular method ; B, At elbow- 
joint, by single external flap ; C, At elbow, 
by oblique circular method. 



AMPUTATION OF UPPER TWO-THIRDS OF FOREARM 

BV EQUAL ANTERIOR AND POSTERIOR FLAPS. 

Description. — The anterior and posterior aspects of the forearm furnish 
equal U-shaped flaps of skin and muscle — the anteriorly largely composed 
of supinator longus and flexors, — the posterior largely made up of extensors. 

Position. — As in the modified circular method (page 356). 

Landmarks. — Saw-line. 

Incisions. — An anterior and a posterior U-shaped flap are incised on 
the respective aspects of the forearm, the base of each flap at the saw-line 
being equal to a half-circumference of the limb at that line, and the length 
of each equal to three-fourths of the diameter — the hand being supinated 
in making the anterior flap, and the forearm vertical in making the posterior 
flap (Fig. 326, B). 



SURGICAL ANATOMY OF THE ELBOW-JOINT. 359 

Operation. — Having cut through skin and fascia in outlining the flaps, 
these incisions are now deepened upon the line of the retracted skin, beginning 
at the ulnar side of the anterior flap, in case of the right arm (and on the 
radial side upon the opposite arm). The vertical ulnar incision will involve 
the flexor carpi ulnaris and flexor profundus — the vertical radial incision 
will involve the two radial carpal extensors — both vertical incisions passing 
directly to the bones. The muscles on the anterior and posterior aspects 
of the forearm, at the lower rounded extremities of the flaps, are cut from 
without inward in such a manner as to bevel them, slightly. The entire flaps 
are now raised from the bones up to a point sufficiently below the saw-line 
to furnish a musculo-periosteal covering — at which level the periosteum is 
circularly divided around the bones — the interosseous membrane cut trans- 
versely — and the musculo-periosteal covering freed to the saw-line. The 
soft parts are then retracted and the bones sawed. The radial, ulnar, anterior 
and posterior interosseous arteries are tied. The median, radial, and ulnar 
nerves should be cut short, or even dissected from the flap. The musculo- 
periosteal covering is sutured and the muscles quilted — and the integuments 
sutured in a lateral line. 

Comment. — These flaps may be less satisfactorily cut by transfixion— 
in which method, also, the interosseous membrane is apt to be pierced. 



SURGICAL ANATOMY OF THE ELBOW-JOINT. 

Bones. — Humerus, radius, and ulna. 

Articulations and Ligaments. — (a) Of the Elbow-joint; — anterior, 
posterior, internal lateral and external lateral ligaments, and synovial mem- 
brane, (b) Of the Superior Radio-ulnar Joint; — orbicular ligament, and 
synovial membrane. 

Muscles in Neighborhood of Elbow. — (A) Muscles arising a greater 
or lesser distance above elbow and inserted below elbow: — (a) On anterior 
aspect; — biceps and brachialis anticus. (b) On posterior aspect; — triceps 
and subanconeus. (c) On radial aspect; — supinator longus and extensor 
carpi radialis longior. (B) Muscles arising from inner condyle of humerus 
and inserted into forearm and hand; — pronator radii teres, flexor carpi 
radialis, palmaris longus, flexor carpi ulnaris, flexor sublimis digitorum. 
(C) Muscles arising from outer condyle of humerus and inserted into forearm 
and hand; — extensor carpi radialis brevior, extensor communis digitorum, 
extensor minimi digiti, extensor carpi ulnaris, anconeus and supinator brevis. 

Muscles in Direct Relation with Elbow-joint. — Anteriorly; brachialis 
anticus. Posteriorly; triceps and anconeus. Externally; supinator brevis 
and common tendon of origin of extensor muscles. Internally; common 
tendon of origin of flexor muscles. 

Arteries in Neighborhood of Elbow. — Brachial, with superior profunda, 
inferior profunda, and anastomotica magna branches. Radial, with radial 
recurrent branch. Ulnar, with anterior ulnar recurrent and posterior ulnar 
recurrent branches. 

Veins in Neighborhood of Elbow. — Superficial; — median, median 
basilic, median cephalic, deep median, radial, cephalic, anterior ulnar, poste- 
rior ulnar, and common ulnar. Deep; — Two venae comites accompanying 
each of above arteries. 

Nerves in Neighborhood of Elbow. — Superficial; — musculocutaneous, 
internal cutaneous, lesser internal cutaneous, external cutaneous, and branches 



360 AMPUTATIONS. 

of triusculospiral. Deep; — ulnar, median, radial and posterior interosseous 
branches of rnusculospiral. 

Bicipital Fascia. — A broad aponeurosis given off from inner side of 
tendon of biceps, opposite bend of elbow — and passing between the brachial 
artery and superficial veins and nerves of elbow obliquely downward and 
inward to become continuous with the deep fascia of forearm, fastening 
down the flexor muscles. 

Bursae in Neighborhood of Elbow. — Between olecranon and skin, and 
between olecranon and triceps. 

Epiphyses. — Portion of epiphysis forming radial condyle and trochlea 
is within the capsule of the joint — that forming the two condyles is without. 
The epiphyses for the trochlea and external condyle blend and join shaft 
about sixteenth or seventeenth year — that for internal condyle, about eighteenth 
year. The upper epiphysis of radius forms the head — is within the joint — 
and joins shaft about sixteenth or seventeenth year. The olecranon is chiefly 
formed by diaphysis — an epiphysis occurs in its summit from the tenth to 
twelfth year— joins shaft about sixteenth or seventeenth year — anteriorly 
the epiphysis being intersynovial, and posteriorly subperiosteal. 

Movements of Elbow- joint. — (1) Flexion — by biceps, brachialis anticus, 
aided by muscles having origin from internal condyle of humerus and by 
supinator longus. (2) Extension — by triceps, anconeus, aided by extensors 
of wrist and by extensor communis digitorum and extensor minimi digiti. 
The cross-sections at and just below the elbow-joint are shown in Figs. 329 
and 29. 



SURFACE FORM AND LANDMARKS OF THE ELBOW. 

Position of radio-humeral line, and hence the joint-line of the elbow, may 
be found by feeling for the depression between the head of the radius and 
capitellum of the humerus at the back of the elbow, marked by a dimple in 
the integument in the interval between the anconeus to the ulnar side, and 
the muscular mass of supinator longus and two carpal radial extensors to 
the radial side. 

The humero-radial articulation is horizontal — the humero-ulnar articu- 
lation slopes slightly downward. 

The fold of the elbow, more prominent when the forearm is semi-flexed, 
is a little above the level of the joint, and forms the base of the triangular 
fossa below the elbow, whose sides are formed by the supinator longus and 
pronator radii teres. 

The inner condyle of the humerus is the more prominent and is a little 
more than 2.5 cm. (1 inch) above the elbow-joint. The outer condyle is 2 
cm. (f inch) above. 

When the forearm is fully extended, the inner condyle, tip of olecranon, 
and external condyle are all on the same transverse line (in extreme extension, 
the tip of the olecranon is slightly above); — when the forearm is flexed to a 
right angle, the tip of the olecranon is directly below the condyles; — when 
the forearm is completely flexed, the tip of the olecranon is below and in 
front of the condyles. 

A line connecting the two condyles forms a right angle with the axis of 
the arm — and an angle with that of the forearm. 



SURGICAL CONSIDERATIONS IN DISARTICULATING ELBOW-JOINT. 361 

The upper part of the olecranon is covered by the triceps — the lower 
part is subcutaneous, and separated from the skin by a bursa. 

Three eminences are present upon the anterior aspect of the elbow region; 
— the biceps above and in the center — the supinator longus and common 
extensor group on the outer — and the pronator radii teres and common 
flexor group upon the inner side. 

The ulnar nerve and posterior ulnar recurrent artery lie in a deep groove 
between the olecranon and inner condyle of the humerus. 

The anterior integument of the elbow is thin and retractile — the posterior 
integument loose and but little retractile. 



GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT 

THE ELBOW- JOINT. 

The stump after disarticulating at the elbow-joint is better for the adapta- 
tion of an artificial limb than after amputation through the arm. 

To find the elbow-joint — place the thumb just beneath the external 
condyle of the humerus and, grasping the wrist with the right hand, pronate 
and supinate the forearm — when the upper limit of the radial head will be 
found about 1.3 cm. (4 inch) below the external condyle. 

The joint is entered and disarticulated more easily from the outer side. 




Fig. 329. — Transverse Section through the Condyloid Expansion of the Right 
Arm: — A, Biceps tendon; B, Supinator longus; C, Musculospiral nerve and superior profundus 
artery; D, Brachialis anticus; E, Extensor carpi radialis longior; F, Olecranon; G, Anconeus; 
H, Triceps; I, Brachial artery, vena; comites, and median basilic vein; J, Pronator radii teres; 
K, Median nerve; L, Flexor carpi radialis; M, Condyloid expansion of humerus; N, Ulnar 
nerve; O, Olecranon bursa. (Cross-section modified from Braune.) 

The muscles on the outer side of the elbow retract more powerfully than 
those upon the inner side, chiefly owing to the presence of the supinator 
longus. 



3^2 AMPUTATIONS. 

The lower end of the humerus is so large that a liberal allowance of covering 
is necessary. And a more liberal covering has to be provided for the inner 
than for the outer condyle of the humerus — incisions, therefore, are longer 
on the inner aspect. 

The skin posteriorly is used to pressure — but the muscles here are not 
so available for padding as in front. 

Temporary drainage should be used after disarticulation. The stump 
should be elevated upon a splint. 



DISARTICULATIONS AT THE ELBOW, IN GENERAL. 

Best Methods. — Anterior Ellipse — best, where ample sound tissue exists; 
well nourished and thick enough to cover bones well; cicatrix well placed; 
but requires considerable tissue; skin-pouch over the olecranon is apt to be 
left. Posterior Ellipse — best where anterior tissue is unavailable; covering 
thin and uneven, though used to pressure. Long Antero-internal and Short 
Postero-external Flaps — cover disarticulated end of humerus well; especially 
indicated where both lateral aspects of forearm can furnish covering and 
neither anterior nor posterior can supply the large amounts of tissue neces- 
sary for the elliptical methods. 

Other Methods. — Circular. Modified Circular. Anterior Flap. Poste- 
rior Flap. Long Anterior and Short Posterior Flaps. Short Anterior and 
Long Posterior Flaps. Single External Flap. Equal Lateral Flaps. Un- 
equal Lateral Flaps. Lateral Skin Flap. Racket Method. Of these 
methods, the circular requires the least sacrifice of parts, but the resulting 
covering is not so satisfactory. 

General Indications. — Tubercular disease; injury or disease of forearm. 



DISARTICULATION OF ELBOW- JOINT 

BY ANTERIOR ELLIPSE — FARABEUF. 

Description. — The covering is, essentially, an anterior flap — the idea 
of the ellipse being gotten in viewing the outlined incision laterally. The 
lower anterior convexity of the covering is sutured into the upper posterior 
concavity. 

Position. — Given in the course of the operation. 

Landmarks. — Joint-line; prominence of olecranon; eminence of supinator 
longus on anterior aspect of forearm. 

Incision. — The highest point of the ellipse is posterior, over the prominence 
of the olecranon. The lowest point of the ellipse is anterior, over the eminence 
of the supinator longus, just above the middle of the forearm. Midway 
between the upper and lower rounded ends of the ellipse the lateral borders 
of the ellipse pass along the mid-lateral aspects of the forearm (Fig. 330, A). 

Operation. — The surgeon stands on the left of either right or left elbow 
(which will place the patient's elbow on his right) — grasping his wrist with 
his left hand, and flexing the elbow, so rotates the limb as to make the entire 
elliptical incision without relaxing his hold of the wrist, or removing the 
knife, which passes from olecranon to olecranon. Taking the right limb, 
for instance, turn the slightly flexed elbow so as to present the radial aspect— 



DISARTICULATION OF ELBOW-JOINT. 



363 



enter the knife at the apex of the olecranon — pass down the radial lateral 
aspect — across the lower end of the ellipse, on the anterior aspect of the 
forearm (with the forearm extended and supine) — then along the inner 
aspect (with elbow again flexed and the inner aspect of the forearm thereby 
made to present) and upward to the olecranon. The skin and fascia 
upon the proximal side of the lower end of this incision are now further 
retracted by hand. On the line of the retracted integuments the muscles are 
then cut obliquely from without inward and upward toward the joint, in such 
a manner as to bevel the anterior covering which is being raised — and, at the 
same time, raise as much of a capsulo-periosteal covering as possible. This 
anterior flap is dissected and retracted upward to the joint-line. The anterior 
lateral and posterior ligaments of the joint are now cut in order. The triceps 
and any remaining posterior tissues are sev- 
ered. The radial, ulnar, interosseous, mus- 
cular branches, and, possibly, the posterior 
ulnar recurrent and terminations of the su- 
perior and inferior profunda are ligated. 
Quilt the muscles in the anterior flap to the 
fascia along the margins of the upper half of 
the ellipse. Suture the integumentary tis- 
sues of the convex lower end of the flap into 
those of the upper concavity. Temporary 
drainage is indicated. 

Comment. — After the integuments are 
incised, the muscles are sometimes, though 
less satisfactorily, cut by thrusting a long 
knife through the limb opposite the anterior g 
aspect of the joint and cutting from within 
outward on a line with the retracted skin. 



DISARTICULATION OF ELBOW- JOINT 

BV POSTERIOR ELLIPSE. 



A 




Fig. 330. — Disarticulations at 
the Elbow-joint: — A, By anterior 
ellipse; B, By long antero-internal 
and short postero-external flaps. 



Description. — The covering is, practi- 
cally, a posterior flap — the idea of the ellipse 
being seen in a lateral view of the incision. 

Position. — Given in the course of the 
operation. 

Landmarks. — Joint-line; tip of olecranon. 

Incision. — The highest point of the 
ellipse is anterior, opposite the lower 
margin of the joint-line. The lowest 
part is posterior, between 8 and 10 cm. 

(3 and 4 inches) below the joint-line. Midway between the upper and lower 
rounded ends of the ellipse, the lateral borders of the ellipse pass along the 
mid-lateral aspects of the forearm. \\ ith the elbow flexed to an angle of 
135 degrees, the lateral parts of the incision will be parallel with the prolonged 
anterior aspect of the arm (Fig. 331). 

Operation. — The surgeon stands on the right of either elbow, grasping 
the patient's wrist with his left hand (the back of his hand uppermost and 
his thumb toward the patient's fingers), and manipulates the elbow so as 
to complete the incision at one sweep — beginning the incision at the anterior 
joint-line with the elbow flexed at the above angle — passing down the inner 



3°4 



AMPUTATIONS. 



aspect (while that part is manipulated so as to render it prominent) — crossing 
the dorsal aspect (while the forearm is held vertical) — ascending the outer 
aspect (while that aspect is made prominent) — to the place of beginning. 
Upon the line of the retracted integuments, the deeper parts are now cut. 
Those along the posterior aspect of the ellipse are divided, together with 
the periosteum, and including the anconeus, and insertion of the triceps when 
reached, and are dissected up to just above the tip of the olecranon. The 
deeper parts along the anterior portion of the ellipse are then divided, corre- 
sponding with the joint-line, and the capsule of the joint divided transversely, 
lollowed by division of the lateral ligaments and posterior portion of the 
capsule (unless a capsulo-periosteal covering can be raised). Tie the brachial, 
posterior interosseous, muscular branches and terminations of the superior 

and inferior profunda. Cut the ulnar nerve 
especially short. Quilt the muscles in the 
posterior flap to the fascia along the mar- 
gins of the upper half of the ellipse. Drain 
temporarily. Suture the integuments of the 
lower portion of the ellipse (the convexity) of 
the posterior flap, to the upper concavity of 
the incision. 

Comment. — Transfixion of the lower 
part of the posterior flap is even less advisable 
than transfixion in the anterior ellipse — as, in 
the former case, the bone is almost subcu- 
taneous. 




DISARTICULATION OF ELBOW- JOINT 

BY LONG ANTERO-INTERNAL AND SHORT POS- 
TERO-EXTERNAL FLAPS. 

Description. — A method of unequal lat- 
eral flaps of skin and muscles — the incisions 
themselves are lateral, the bulk of the mus- 
cles being antero-internal and postero-ex- 
ternal. 

Position. — The forearm is held in supi- 
nation during anterior incisions — and verti- 
cal during posterior incisions, or partly flexed. 
Landmarks. — Elbow joint-line; tip and 
base of olecranon. 
Incisions. — Antero-internal incision — begins at center of anterior aspect 
of the joint-line — passes obliquely downward and inward over the forearm, 
in such a way as to meet the mid-lateral aspect of the forearm, on the ulnar 
side, at a distance of about 7.5 cm. (3 inches) below the joint-line — thence 
passes upward and backward along a corresponding line to the base of the 
olecranon. Postero-external incision — a shorter incision but very similar to 
the longer, passes between the same points, crossing the mid-lateral aspect 
of the forearm, on the radial side, about 2.5 cm. (1 inch) below the joint- 
line (Fig. 330, B). This is practically an internal and external flap. 

Operation. — Along the line of these retracted integuments the muscles 
are cut obliquely down to the bone — when they, and as much of the periosteum 



Fig. 331. — Disarticulation of 
Elbow by Posterior Ellipse? 



SURGICAL ANATOMY OF THE ARM. 



365 



as possible, are dissected up to the joint-line in front, and to the tip of the 
olecranon behind. The elbow is then flexed — the triceps is divided at its 
attachment to the olecranon — and disarticulation completed by dividing the 
posterior, lateral and anterior ligaments, in order. Tie the brachial, termina- 
tions of the superior and inferior profunda, and, possibly, some small muscular 
and articular branches. The large antero-internal flap folds over the articular 
end of the humerus— its muscles are to be quilted to those of the smaller flap 
— and the integuments of the two flaps sutured — placing the cicatrix upon 
the externo-terminal aspect of the joint. 





Fig. 332. — Disarticulation at 
Elbow : — By long anterior and short 
posterior flaps. 



Fig. 333. — Disarticulation at 
Elbow : — By long posterior and short 
anterior flaps. 



SURGICAL ANATOMY OF THE ARM. 

Bones. — Humerus. 

Muscles of the Arm. — (A) Anterior Humeral Region: — coracobrachial, 
biceps, brachialis anticus. (B) Posterior Humeral Region: — triceps, sub- 
anconeus. (C) Muscles having their insertions in upper portion of humerus: 
— supraspinatus, infraspinatus, teres minor, subscapularis, pectoralis major, 
latissimus dorsi, deltoid, teres major. (D) Muscles having their origin 
from lower portion of humerus: — (a) From internal condyle and ridge: — 
pronator radii teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, 
flexor sublimis digitorum — (b) From external condyle and ridge: — supinator 
longus, extensor carpi radialis longior, extensor carpi radialis brevior, ex- 
tensor communis digitorum, extensor minimi digiti, extensor carpi ulnaris, 
anconeus, supinator brevis. 

Arteries of Humeral Region. — From Axillary: — acromial and humeral 
branches of acromial thoracic, subscapular, anterior circumflex, posterior 
circumflex, and axillary itself. From Brachial: — superior profunda, nutrient, 



366 AMPUTATIONS. 

inferior profunda, anastomotica magna, muscular, and brachial itself. From 
Radial: — radial recurrent. From Ulnar: — anterior ulnar recurrent, posterior 
ulnar recurrent. 

Veins of Humeral Region. — Superficial: — cephalic, basilic, Deep: — 
two vente comites accompany each of above branches of main arteries, and 
also brachial artery. Axillary vein is formed by two brachial venae comites 
and basilic vein. 

Nerves of Humeral Region. — Anteriorly: — musculocutaneous, median, 
internal cutaneous, ulnar, lesser internal cutaneous, intercosto-humeral. 
Posteriorly: — circumflex, musculospiral. The cross-sections of the arm are 
shown in Figs. 25, 27, and 335. 

SURFACE FORM AND LANDMARKS OF THE ARM. 

The humerus is almost entirely covered by muscles, being subcutaneous 
only at the internal and external condyles. The greater and lesser tuber- 
osities and the head may be defined. The greater tuberosity lies just below 
the antero-external aspect of the acromion. The lesser tuberosity lies to the 
inner side of and below the greater, the bicipital groove intervening. To 
feel the head of the bone, abduct the arm, when the head will project promi- 
nently into the axilla. 

The internal condyle and internal condyloid ridge, and external condyle 
and external condyloid ridge, can be felt just above the elbow-joint. The 
latter are more easily felt during semiflexion, as a depression between adjacent 
muscles. 

The greater tuberosity and external condyle are in the same straight line 
and face in the same direction. The head of the humerus and the internal 
condyle are also in the same straight line and likewise face in the same direc- 
tion. 

When the arm hangs by the side, the bicipital groove looks directly for- 
ward. 

The rough prominence upon the outer aspect of the middle of the humerus, 
into which the deltoid is inserted, also marks the level of the insertion of the 
coracobrachialis and the origin of the brachialis anticus — and also the 
entrance of the nutrient artery into the bone, and the level at which the 
musculospiral nerve and superior profunda artery cross the back of the bone. 

The upper epiphysis is horizontal and placed just above the surgical 
neck, joining the shaft at the twentieth year. 

The coracobrachialis and biceps above, and the biceps below, form the 
prominent muscular mass of the front of the arm. The brachialis anticus is 
discernible at the lower part of the arm, on each side of the biceps. 

The triceps determines the form of the back of the arm. The inner head 
is least distinct. The outer head forms the large prominence just below the 
posterior border of the deltoid. The long head emerges from between the 
teres major and minor and descends along the back of the arm. 

The supinator longus and extensor carpi radialis longior form a prom- 
inence on the outer side of the lower portion of the arm. 

Above the middle of the arm, the biceps, deltoid, coracobrachialis, and 
long head of triceps are more or less free and capable of retraction. Below 
the middle of the arm, the biceps is the only free muscle. It is for this reason 
that the circular method of amputation is suitable only to the lower half of 
the arm. 

In women and in fat persons the contour of the arm is more rounded 



SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT ARM. 367 

and more nearly of one size throughout. In the muscular, it is less regular 
and more flattened laterally. 

On the inner and outer sides of the biceps are found the inner and outer 
bicipital furrow,— the cephalic vein occupying the latter — and the brachial 
artery and basi'ic vein the former. 

The superior profunda artery arises just below the outlet of the axilla — 
the inferior profunda opposite the center of the shaft — and the anastomotica 
magna about 5 cm. (2 inches) above the bend of the elbow. 

The skin is most retractile over the inner aspect of the arm. 




Fig. 334. — Transverse Section through the Lower Third of the Right Arm: — 
A, Biceps; B, Brachialis anticus; C, Musculospiral nerve and superior profunda artery; G, 
Supinator longus; D, Brachial artery, vena; comites, basilic vein, and median nerve; E, Ulnar 
nerve and superior profunda artery; F, Triceps. (The cross-section modified from Braune.) 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE ARM. 

The shortest stump of an arm, even an amputation at the surgical neck, 
is better than a shoulder-joint disarticulation — as such a stump will ordinarily 
be able to move an artificial limb. It is, therefore, desirable to retain as 
much of the humerus as possible, as leverage for the artificial limb. 

From the standpoint of the amputator, the arm may be divided into two 
natural regions — a lower third, more or less cylindrical, and where the muscles 
are largely attached to bone — and an upper two-thirds, more or less conical, 
flattened or irregular, and where the muscles are largelv free and capable 
of retraction. Therefore a circular method of amputation is preferable for 
the lower third, and a flap method for the upper two-thirds. 

The surgical neck of the humerus marks the height at which a useful 
stump can be obtained, as the capsule extends down to its level internally. 



368 AMPUTATIONS. 

In amputating at the surgical neck, the bone is sawed between the tuber- 
osities, and insertions of the pectoralis major and teres major. The supra- 
spinatus, infraspinatus, teres minor, and subscapularis are left attached to 
the head of the humerus. The bone is sawed below the epiphyseal line. 
The synovial membrane of the joint (accompanying the biceps tendon) is apt 
to be opened on the inner aspect, where it is lowest. The bursa under the 
subscapularis tendon generally communicates with the joint and may be 
opened during the operation. As much of the attachment of the pectoralis 
major, teres major, and latissimus dorsi as possible is raised with the peri- 
osteum, so as to be included in the musculo-periosteal covering of the end 
of the bone and in the quilting of the muscles, in order to retain the attach- 
ments of these muscles upon the stump and, therefore, their action upon 
the artificial limb. 

In an amputation through the upper two-thirds by an anterior flap twice 
as long as the posterior, the scar will eventually be terminal, owing to the 
much greater retraction of the anterior parts — the biceps contracting most of 
any muscle. A terminal cicatrix is sought in the stumps of the arm. 

The stump should be dressed upon a splint. 

For control of hemorrhage in amputating at the shoulder joint, see page 374. 



AMPUTATION OF THE ARM, IN GENERAL. 

Best Methods. — Modified Circular — best for the lower third. Long 
Anterior and Short Posterior Flaps — best for the upper two-thirds. Single 
Externa] Flap — best at the surgical neck. 

Other Methods. — Simple Circular (infundibular form). Single Anterior 
Flap (Malgaigne's method). Anterior Ellipse (practically an anterior flap). 
Posterior Ellipse (practically a posterior flap). Lateral Flaps (of skin and 
muscles). Rectangular Flap (Teale's method). Oval Method (at the surgi- 
cal neck). 

General Indications. — Extensive crushes of upper extremity; tubercular 
osteo-arthritis; sarcoma; tumors of elbow. 

AMPUTATION THROUGH THE LOWER THIRD OF THE ARM 

BY MODIFIED CIRCULAR METHOD. 

Description. — Two short skin-flaps are cut and turned back, and the 
muscles divided circularly in the infundibular manner. 

Position. — Patient supine, at edge of table; limb horizontally abducted 
over the edge of table during anterior incisions, and held vertically, with 
bent elbow, or drawn over the chest, in dorsal incisions. Surgeon on outer 
side of right and inner side of left limbs. Assistants steady the limb above 
and below the site of amputation. 

Landmarks. — Saw-line. 

Incision. — The lowest limit of the skin incision is placed at a distance 
below the saw-line equal to three-fourths of the diameter of the limb at 
the saw-line (thus securing a covering of ij diameters). Of this total dis- 
tance the small flaps will occupy, approximately, the lower one-third. These 
flaps are generally anterior and posterior (but may be lateral, or in any 
intermediate position, as the local conditions may demand). Their base is 
one-half the circumference of the limb — they pass down the lateral aspects 
of the limb to nearly their lower limit, when the}- bluntly round transversely 



AMPUTATION THROUGH THE LOWER THIRD OF THE ARM. 369 

across the limb to a corresponding point on the opposite side. The anterior 
and posterior daps are similar (Fig. 335, A). 

Operation. — These flaps of skin and fascia are freed up to their base 
and turned back as cuffs. Here the more superficial muscles are circularly 
divided, and retracted in turn. Upon the line of these retracted superficial 
muscles, the deeper muscles are cut to the bone — at a level still beneath the 
saw-line. This last circular division also divides the periosteum around 




Fig.335.— Amputations through Arm and at Shoulder :— A, Through lower part of arm, 
by modified circular ; B, Through upper part of arm, by long anterior and short posterior flaps ; C, 
At shoulder-joint, by external racket method (Larrey's operation) ; D, D, At shoulder, by external, or 
deltoid, flap (Dupuytren's operation). 



the entire bone. All the soft parts, including the periosteum, are now freed 
up to the saw-line and the bone divided. Tie the brachial, superior pro- 
funda, inferior profunda, muscular, and possibly the anastomotica magna, 
branches. See that the musculospiral nerve is cleanly divided, and excise 
any portion of it apt to be pressed upon in bending the flap over the end of 
bone. Suture the musculo-periosteal covering. Quilt the muscles. Suture 
the flaps in a lateral line. 



37° AMPUTATIONS. 

Comment. — (i) The modified circular method makes it easier to free 
the bone of soft parts up to the saw-line, and also furnishes a more sym- 
metrical terminal covering. If necessary, the skin-flaps may represent one- 
half of the distance between the saw-line and the lowest limit of the skin- 
incision. (2) The simple circular method (the infundibular form) mav be 
done here in small limbs with flabby coverings — but would be difficult in 
large limbs with firm coverings. When the infundibular circular method is 
used, it should be an oblique circular, the circle dipping lower on the antero- 
internal aspect of the arm, where, owing to greater retraction, it will be sub- 
sequently drawn up to the level with the outer part. 



AMPUTATION OF THE UPPER TWO-THIRDS OF THE ARM 

BY LONG ANTERIOR AND SHORT POSTERIOR FLAPS. 

Description. — Two U-shaped flaps of skin and muscle are raised, the 
posterior being one-half the length of the anterior. 

Position. — As in the last operation. 

Landmarks. — Saw-line. 

Incisions. — The base of each flap equals one-half circumference at the 
saw-line. The length of the anterior flap is equivalent to one diameter at 
the saw-line. And the length of the posterior flap is one-half the diameter. 
Both are U -shaped flaps. Care is taken to place these flaps so that the brachial 
artery will not be apt to be split — the vessel should be in the posterior flap — 
and the points of junction of the two flaps on the inner and outer aspect of 
the arm should be so shifted toward the outer side as to make this certain. 
The arm is raised vertically while the posterior flap is being marked out 
and incised (Fig. 335, B). 

Operation.- — Having incised skin and fascia along the above lines, the 
muscles are divided along the retracted integumentary coverings — cutting 
to the bone along the vertical limbs of the flaps, and cutting obliquely inward 
and upward along the rounded transverse endings of the flaps, in a bluntly 
beveled fashion — coming down upon the bone sufficiently far below the saw- 
line to provide a periosteal covering, which, with the muscles, is freed up to 
the saw line — and the bone divided. Care is taken to divide the musculo- 
spiral nerve evenly and short — as well as the nerves in the anterior flap which 
bend over the end of the bone, partially excising them if necessary. Tie the 
brachial, superior profunda, and inferior profunda, and muscular branches. 
Quilt the muscles of the anterior to those of the posterior flap — the former 
chieflv covering the end of the bone. Suture the skin margins of the flaps. 
The limbs should be steadied by a splint which also includes the shoulder. 



AMPUTATION OF ARM AT SURGICAL NECK 

BY SINGLE EXTERNAL FLAP. 

Description. — A U-shaped flap, composed chiefly of deltoid, is raised 
from the outer aspect of the arm, while the parts on the inner aspect are 
divided transversely, or with slight downward convexity, on a level with the 
upper limit of the limbs of the flap. 

Position. — As in the above operations — the limb being drawn well away 
from the body, which will give access to both outer and inner aspects. 

Landmarks. — Surgical neck of humerus (just below the tuberosities). 



AMPUTATION OF ARM AT SURGICAL NECK. 



371 



Incisions. — Flap incision — the base of the flap, which is U-shaped, is 
placed about 2.5 cm. (1 inch) below the saw-line through the surgical neck — 
its width being equal to half the circumference of the limb at the flap's upper 
limit — its length being that of the diameter at the saw-line. The anterior 
limb of the flap passes down the mid-anterior aspect of the arm, and the 




Fig. 336.— Amputations about Arm and at Shoulder: — A, Through lower part of arm, by 
equal lateral flaps; B, Through surgical neck of humerus, by single external flap; C, At shoulder- 
joint, by Furneaux Jordan's method. 

posterior limb down the mid-posterior aspect. Inner incision — crosses the 
inner aspect of the arm, with a slight downward convexity, connecting the 
upper limits of the vertical limbs of the flap (Fig. 336, B). 

Operation. — The above incisions pass, at first, through skin and fascia 
only. After the integuments have retracted, the external flap is cut from 
without inward, upon the line of the retracted tissues, beveling obliquely 
upward and inward toward the upper limit of the flap. The bleeding vessels 
in this external wound are clamped as met. The inner incision is now deep- 
ened — and the axillary vessels tied as encountered and before being cut — 



37 2 AMPUTATIONS. 

and the nerves cut short. The tendon of the pectoralis major is preserved, 
the periosteum being divided below the bicipital groove and stripped up, 
including this tendon. Avoid opening the synovial sheath of the biceps 
tendon, dividing it low down, together with the coracobrachialis. Detach 
the tendons of the latissimus dorsi and teres major as subperiosteal^ as 
possible. Retract the outer flap and the parts on the inner aspect of the arm 
up to the saw-line — and divide the bone through the lowest part of the surgical 
neck possible. Avoid the circumflex nerve and the posterior circumflex 
artery. The brachial artery will have been tied in the course of operation — 
branches of the anterior and posterior circumflex and muscular branches 
which have not been previously tied are now taken up. Bring the outer 
flap across the end of the bone — quilt the muscles of the flap to those divided 
in the inner incision — and suture the integumentary portion of the flap trans- 
versely to corresponding tissues of the inner wound. Dress the arm against 
a full pad in the axilla. 

Comment. — ( i) The chief advantages of amputation through the surgical 
neck, over disarticulation at the shoulder, are, that the mortality is less; 
that a stump for an artificial limb is secured; and that there is not so much 
muscular atrophy. The chief disadvantages are, that the remaining epiph- 
ysis is apt to produce bone; and that the stump may be strongly abducted. 
(2) The outer flap may be less satisfactorily cut by transfixion. 



SURGICAL ANATOMY OF SHOULDER- JOINT. 

Bones. — Scapula; clavicle; humerus. 

Articulations and Ligaments. — (a) Acromio-clavicular Articulation: — 
superior acromio-clavicular, inferior acromio-clavicular ligaments; inter- 
articular fibro-cartilage; synovial membrane, (b) Coraco-clavicular Union: — 
trapezoid and conoid ligaments, (c) Shoulder-joint: — capsular, gleno- 
humeral bands of capsular, coraco-humeral, glenoid and transverse humeral 
ligaments, and synovial membrane. 

Muscles Reinforcing Shoulder-joint. — Above: — supraspinatus. Be- 
low: — long head of triceps; an upward extension of pectoralis major. In- 
ternally: — subscapularis. Externally: — infraspinatus; teres minor. Within 
Joint: — long head of biceps. Surrounding Joint: — deltoid. 

Muscles in More or Less Direct Relation with Shoulder-joint. — (a) 
Anterior Thoracic Region: — pectoralis major, pectoralis minor, subclavius. 
(b) Lateral Thoracic Region: — serratus magnus. (c) Acromial Region: — 
deltoid, (d) Anterior Scapular Region: — subscapularis. (e) Posterior Scapu- 
lar Region: — supraspinatus, infraspinatus, teres minor, teres major, (f) 
Muscles Passing from Shoulder to Arm Anteriorly: — biceps, coracobrachialis. 
(g) Muscles Passing from Shoulder to Arm Posteriorly: — triceps. 

Movements of Shoulder-joint. — Forward: — pectoralis major, anterior 
fibers of deltoid, coracobrachialis, biceps (when elbow is flexed). Backward: 
— latissimus dorsi, teres major, posterior fibers of deltoid, triceps (when 
elbow is extended). Abduction: — deltoid, supraspinatus. Adduction: — 
subscapularis, pectoralis major, latissimus dorsi, teres major. Outward 
Rotation: — infraspinatus, teres minor. Inward Rotation: — subscapularis, 
latissimus dorsi, teres major, pectoralis major. 

Bursa? in Neighborhood of Joint. — Beneath tendon of subscapularis 
— communicating with joint by opening on anterior side of capsule. Beneath 
tendon of infraspinatus (sometimes present) — communicating with joint by 



SURFACE FORM AND LANDMARKS OF SHOULDER- JOINT. 373 

opening on posterior aspect of capsule. Between under surface of deltoid 
and outer surface of capsule — not communicating with joint. Biceps tendon 
passes through the joint and is surrounded by tubular sheath continuous 
with synovial membrane. 

Arteries in Neighborhood of Shoulder-joint. — Suprascapular, trans- 
versalis colli, superior thoracic, acromial thoracic, long thoracic, alar thoracic. 
subscapular, anterior circumflex, posterior circumflex. 

Veins in Neighborhood of Shoulder-joint. — Two suprascapular, two 
transversalis colli, superior thoracic, acromial thoracic, long thoracic, alar 
thoracic, subscapular, anterior circumflex, posterior circumflex, cephalic 

Nerves in Neighborhood of Shoulder-joint. — Acromial branch of 
cervical plexus, posterior thoracic, suprascapular, external anterior thoracic, 
internal anterior thoracic, upper subscapular, lower subscapular, middle 
subscapular, circumflex, — and following passing through axilla to arm and 
forearm; musculocutaneous, internal cutaneous, lesser internal cutaneous, 
median, ulnar, musculospiral. 



SURFACE FORM AND LANDMARKS OF SHOULDER- JOINT. 

To find the direction and position of the shoulder-joint — having fully 
abducted the arm, draw a slightly curved line from the middle of the coraco- 
acromial ligament, with convexity inward, to the innermost part of the head 
of the humerus felt in the axilla. 

The coracoid process is not actually within the infraclavicular fossa, but 
lies near the pectoro-deltoid groove, covered by the anterior fibers of the 
deltoid, and a little below the clavicle. 

The center of the coraco-acromial ligament lies over the superior aspect 
of the shoulder-joint. 

The greater tuberosity of the humerus is felt externally — the lesser ante- 
riorly. To the former are attached the supraspinatus, infraspinatus, and 
teres minor, in order, from above downward. To the lesser — the subscapularis. 

With the arm by the side and the hand supine, the bicipital groove looks 
directly forward — the head of the humerus lying entirely to the outer side 
of the vertical line from the coracoid process. The head of the humerus 
faces, practicallv, in the direction of the inner condyle — and the greater 
tuberosity in the direction of the outer condyle. 

The upper epiphysis of the humerus unites with the bone about the 
twentieth year — the inner part of the cartilage is within the capsule of the 
joint — the outer, anterior and posterior parts are subperiosteal. 

The surgical neck lies between the bases of the tuberosities and the inser- 
tions of the latissimus dorsi, teres major, and pectoralis major. 

The deltoid gives the rounded outline to the shoulder — and its insertion 
is marked by a depression on the outer aspect of the middle of the arm. 

The groove between the pectoralis major and deltoid contains the cephalic 
vein and the humeral branch of the acromio-thoracic artery. 

The acromio-thoracic artery emerges from the upper border of the pec- 
toralis minor in the course of the brachial artery, where a line from near the 
junction of the third rib and its cartilage to the coracoid process crosses that 
vessel. 

The posterior circumflex artery and circumflex nerve cross the surgical 
neck of the humerus transversely about 1.3 cm. (h inch) above the center 
of the vertical axis of the deltoid. 



374 



AMPUTATIONS. 



The skin over the deltoid is thick, adherent, and little retractile — that 
over the pectoralis major is fine and retractile. 

The dorsalis scapulae artery crosses the axillary border of the scapula 
opposite the center of the vertical axis of the deltoid. 



GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT 

SHOULDER- JOINT. 

Methods of Hemorrhage-control during operations near the Shoulder- 
joint — (a) Wyeth's Shoulder Transfixion Pins, with tubular rubber Tourni- 
quet placed above them; — The anterior pin (Fig. 337, A) enters the middle 
of the anterior axillary fold, slightly to the inner side of the center of the fold — 

D A 

u A 




tig. 337. — Wyeth's Pins Controlling Hemorrhage in Disarticulation at the 
Shoulder-joint: — A Anterior pin; B, Posterior pin. The rubber tubing is then wound about 
the limb proximally to the pins and knotted. 



Fig. 337- 



and emerges 2.5 cm. (1 inch) within the tip of the acromion process. The 
posterior pin (Fig. 337, B) enters the posterior axillary fold, at a point corre- 
sponding with the entrance of the anterior pin — and similarly emerges poster- 
iorly 2.5 cm. (1 inch) within the tip of the acromial process. Care is neces- 
sary to avoid striking the spine of the scapula with the posterior pin. Rubber 
tubing of 1.3 cm. (£ inch) diameter is wound several times around the axilla, 
above the pins, and tied (Fig. 268, right shoulder), (b) Where the special 
pins are not at hand, the tube has been held in place by several sutures passed 
through the true skin and temporarily tied over the tubing, after it has been 
knotted. The tubing is thus prevented from slipping when the soft parts 
recede, or sink in, after the head of the humerus is removed. The method, 
however, is less satisfactory than the use of the pins (Fig. 338). (c) J. Lynn 
Cardiff has devised a clever forceps-tourniquet for controlling hemorrhage 
during operations upon the extremities. It consists of a clamp, one blade of 



SURGICAL CONSIDERATIONS IN SHOULDER DISARTICULATIONS. 375 

which is probe-pointed, the other serrated. In the interscapulo-thoracic 
amputation a limited incision is made, exposing the lower edge of the pectoral 
muscle in the mid-axilla — through this the probe-pointed blade of the clamp 
is thrust and carried onward and upward beneath the pectoral muscles and 
the axillary vessels and nerves — to emerge through the wound previously made 
for the purpose of dividing the clavicle (Fig. 339). The instrument is then 




Fig. 338.— Illustrating the Use of Sutures Passed through the True Skin and 
Temporarily tied over Rubber Tubing to hold it in Place: — Used in order to control 
the vessels in disarticulating at the shoulder-joint in the absence of the Wyeth pins. 



clamped — thus compressing the muscles and axillary structures between the 
probe-pointed and serrated blades. The soft parts are then divided distally 
to the clamp — the vessels are brought within easy reach — and the ligatures 
are placed (Fig. 340). The points of entrance and exit of the probe-pointed 
blade are made to correspond with some part of the incision for the interscapulo- 
thoracic amputation, (d) Preliminary exposure and double ligation of the 
axillary artery, with division between the two ligatures (as in Larrey's oper- 
ation, page 381). (e) Digital compression of the main artery in the flap by 
an assistant, who grasps the part just prior to division of the artery (as in 
Spence's operation, page 378). (f) By Tourniquet and Pad; — A firm pad 
is placed in the axilla — over tins are placed several turns of rubber tubing 
passing around the axilla — the ends are then carried in a single figure-of-eight 
fashion over the clavicle of the same side, and thence across the chest and are 
tied beneath the opposite axilla. Two strips of sterile gauze run beneath 
the tubing anteriorly and posteriorly (or placed in position prior to applying 
the tubing) will enable the tubing to be further and more securely drawn 
inward and thus make less the chances of slipping when the head of the humerus 
is removed (Fig. 268, left shoulder), (g) Compression (digital or instru- 
mental) of subclavian artery against the first rib, either with or without pre- 
liminary incision over the third part of the artery, through the superficial 
tissues, (h) Securing of the main vessels at the lower end of the incision, as 



376 



AMPUTATIONS. 



met in the course of the operation — an ordinary tourniquet having been first 
applied — (as in the Fourneaux Jordan method) . 

Comparison of methods of hemorrhage-control:— The control of hemor- 
rhage in disarticulating at the shoulder-joint, or in amputating very near 
the shoulder articulation, is the most serious consideration connected with 
these operations. Wyeth's method, where the pins do not interfere with the 
operation as planned, may be regarded as the best means against hemorrhage. 
Preliminary exposure and ligation of the artery — and compression of the 
artery in the flap— may be regarded as the next best methods. 




Fig. 339. — Thomas' Forceps-tourniquet for Controlling Hemorrhage during 
Operations itpon the Extremities: — The probe- pointed blade passes under the pectoral 
muscles and axillary vessels and nerves, and the serrated blade over these structures — the former 
coming out above the region of the previously divided clavicle. (Modified from Thomas.) 



The axillary vessels should be as cleanly cut as possible — and so approached 
as to be secured before being cut, where the method of preliminary ligation 
is adopted. 

The branches of the brachial plexus are to be divided high up. 

The acromial process should always be preserved — as it furnishes a 
support for the artificial limb. 

A capsulo-periosteally covered stump should be sought — as furnishing 
the best support for an artificial limb — therefore one should endeavor to 



DISARTICULATION AT SHOULDER-JOINT, IN GENERAL. 



377 



detach the insertions of the pectoralis major, latissimus dorsi, teres major, 
subscapularis, supraspinatus, infraspinatus, and teres minor along with the 
periosteum and capsule, in so far as this is possible. 

A vertical wound, in closing the site of operation, affords the best drainage. 
Sometimes drainage is made through a secondary opening. Temporary 
drainage is always indicated — owing to the extensive synovial surfaces. 

The stump should be dressed so as to compress dead spaces — and steadied 
against the thorax as a splint by the surrounding bandaging. 




Fig. 340. — Thomas' Forceps-tourniquet: — The pectoral muscles and axillary structures 
have been divided distally to the clamp and turned forward. Note: — the probe-pointed blade 
is here erroneously shown to be where the serrated blade should be, and vice versa. The correct 
position of the blades is shown in the preceding illustration. (Modified from Thomas.) 



DISARTICULATION AT SHOULDER- JOINT, IN GENERAL. 

Best Methods. — Anterior Racket Method (Spence's operation). Ex- 
ternal Racket Method (Larrey's operation). External or Deltoid Flap 
(Dupuytren's operation). 

Other Methods. — Anterior and Posterior Flaps. Circular. Elliptical. 
Lateral Flaps. Fourneaux Jordan's Method. 

Comparison of Methods. — The racket methods are the best. The 
features of the anterior racket method are: — excision of the shoulder-joint 



378 AMPUTATIONS. 

may be done, instead of an amputation, through the vertical portion of the 
incision, which may be alone made at first, until it be found whether ampu- 
tation be necessary; there is the smallest division of muscle; the posterior 
circumflex artery and circumflex nerve are not cut; the main vessels are 
easily controlled. The features of the external racket method are: — the 
vertical portion of the incision also allows of an excision, the incision at first 
being exploratory, through which an excision of the joint may be made, or 
the operation may be converted into an amputation; there is considerable 
division of muscle and the joint is more deeply placed than in the anterior 
racket; the posterior circumflex artery and circumflex nerve are apt to be cut. 
The disadvantages of the external or deltoid flap, which may be regarded 
as probably the third best form of disarticulation, are, that the circumflex 
nerve and posterior circumflex artery are cut — and that preliminary exami- 
nation of the joint is impossible. 

General Indications. — Tumors of arm; extensive injury of arm; com- 
pound comminuted fractures; gunshot injuries; chronic disease of shoulder- 
joint; gangrene of upper limb; extensive osteomyelitis; extensive tumor masses 
of shoulder and scapula. 



DISARTICULATION AT SHOULDER- JOINT 

BV ANTERIOR RACKET METHOD — SPENCE'S OPERATION. 

Description. — The queue of the incision is placed over the anterior 
aspect of the upper end of the humerus — the diverging limbs of the racket, 
or oval, encircling the inner and outer aspects of the arm and meeting behind. 

Position. — Patient near edge of table; shoulders elevated; head to oppo- 
site side; limb partly abducted. Surgeon on outer side of both shoulders, 
or may stand on inner side of left. First assistant stands between shoulder 
and patient's head, controls hemorrhage and retracts flaps. Second assistant 
stands near elbow and manipulates limb. 

Landmarks. — Coracoid process; pectoro-deltoid groove. 

Incision. — Abduct the arm and rotate the head of the humerus outward. 
Begin the incision just to the outer side of the coracoid process — pass down 
through the clavicular fibers of the deltoid and pectoralis major, until the 
humeral attachment of the pectoralis major is reached, which is divided. 
From this point, the outer limb of the racket curves gently outward through 
the lowest part of the deltoid to the posterior border of the axilla. From 
the point of division of the humeral attachment* of the pectoralis major, the 
inner limb of the racket curves downward across the inner aspect of the arm — 
until it coincides with the opposite limb of the racket (Fig. 341, B). 

Operation. — (I) The vertical portion of the incision is carried directly 
to the bone. The outer limb of the racket at first passes through skin and 
fascia, and is then deepened to the bone and through the periosteum, along 
the line of the incised integuments. The inner limb of the racket merely 
passes through skin and fascia, and especial care is taken that it goes no 
deeper at this stage. (2) Returning to the outer lip of the wound, the anterior 
fibers of the deltoid will be found divided, and this lip of the wound is now 
freed from the bone and joint, as nearly subperiosteally as possible, thereby 
securing the retention of some of the attachments of the pectoralis major, * 
latissimus dorsi, and teres major to the fibrous tissue — the freeing being 
accomplished by means of the thumb, periosteal elevator and knife, and 
continuing up to the great tuberosity — carefully avoiding (by hugging the 



DISARTICULATION AT SHOULDER-JOINT. 



379 



bone) injury to the circumflex nerve and posterior circumflex artery, which 
are raised from the bone in this outer flap. (3) The inner lip is similarly, 
though less extensively, freed up to the lesser tuberosity, carefully guarding 




Fig. 341.— Amputations through Arm and at Shoulder :— A, Through lower arm, by oblique 
circular method ; B, At shoulder, by anterior racket method (Spence's operation) ; C, Of upper limb, 
together with scapula and part of clavicle, by antero-inferior (pectoro-axillary) and postero-superior 
(cervico-scapular) flaps (Berger's operation). 



the axillary vessels. (4) By manipulating the limb from the elbow, flexed 
at a right angle, the head of the bone and its tuberosities are made to present 
themselves in the wound. By rotating inward, the great tuberosity presents, 
and the supraspinatus, infraspinatus, and teres minor are severed very close 



380 AMPUTATIONS. 

to the bone. By rotating outward, the lesser tuberosity presents, and the 
subscapularis is severed. (5) The long head of the biceps is next cut, and 
the capsule opened by dividing it transversely against the head of the bone. 
The capsule being cut and the muscles attached to the tuberosities severed, 
the head of the bone is now disarticulated and thrust upward above the 
glenoid cavity, by abducting and rotating the head of the humerus outward — 
the connection of the limb being maintained by the still unsevered tissues 
upon the inner aspect. (6) The surgeon grasps the disarticulated head with 
the left hand and draws it outward from the trunk. As he does so, the first 
assistant, standing behind the shoulder, places the palm of the fingers of 
both hands against the axillary aspect of the still uncut inner tissues, and his 
thumbs, one from each side, between the neck of the bone and the tissues 
of the inner side, compressing the axillary vessels between the thumbs in the 
wound and the outspread fingers in the axilla — until he feels all circulation 
controlled. The surgeon now passes a long knife between the neck of the 
bone and the thumb-nails of his assistant, and, by a steady, sawing move- 
ment, cuts his way from within downward and outward, aiming to come out 
on a line with the retracted integuments along the original incision, along 
me inner limb of the racket. As the knife cuts its way out, the fingers of 
the assistant follow the blade closely, with the artery under his grasp. Just 
prior to the final passage of the knife, the tissues are tightly grasped and 
steadilv held, until the knife emerges — when he presents to the surgeon the 
cut margin of the inner flap, with the vessels in easy evidence. (7) Tie the 
brachial artery at once, and the two brachial venae comites and the basilic 
vein. In the vertical and external limb of the racket, in incising and deepen- 
ing the wound, branches of the acromial thoracic, the anterior circumflex, 
and muscular branches are at first clamped and subsequently tied. (8) The 
posterior circumflex nerve should not be injured. The nerves which are 
severed are cut short. (9) The margins of the capsulo-periosteal wound, 
where any appreciable periosteum has been saved, are sutured. The muscles 
are quilted by deep and superficial tiers of buried catgut (chromic) sutures. 
Temporary drainage is provided. The integumentary edges of the wound 
are sutured in one vertical line. The stump should be snugly compressed 
against the thorax by the bandage. 

Comment. — (1) This operation is an illustration of the control of hemor- 
rhage by digital compression in the flap. (2) By saving as much of the 
attachment of the pectoralis major, latissimus dorsi and teres major, in the 
subperiosteal freeing of the humerus, connections in the stump are formed 
by these tendons and considerable range of movement is thereby added to 
an artificial limb. (3) The axillary vessels have been exposed where the 
inner limb of the racket crosses their course and ligated prior to disarticula- 
tion. (4) Where the deltoid tissues are very thick, this flap may be ad- 
vantageously thinned a little by making the incision of the outer limb of the 
racket in a beveling manner. (5) The more nearly the operation is done 
subperiosteallv, where no contraindication to the preservation of the peri- 
osteum exists, the greater the safety to the important tissues, especially the 
circumflex nerve and posterior circumflex artery. 



DISARTICULATION AT SHOULDER-JOINT. 381 

DISARTICULATION AT SHOULDER- JOINT 

BY EXTERNAL RACKET METHOD — LARREY'S OPERATION. 

Description. — The queue of the incision is placed oYer the external 
aspect of the upper end of the humerus — from the center of this incision 
(which may first haYe been made for exploration of the joint alone) the two 
limbs of the racket diverge — encircling the anterior and posterior aspects 
of the arm and meeting on the inner side. 

Position. — As in Spence's operation (page 378). 

Landmarks. — Prominence of acromion. 

Incisions. — d) Vertical incision — (arm being slightly abducted) begins 
immediately below the anterior aspect of the prominence of the acromion 
and passes thence vertically down the external aspect of the arm for 10 cm. 
(4 inches). (2) Oval incision — from the center of the vertical incision the 
two limbs of the oval, or racket, begin and pass obliquely downward over 
the anterior and posterior aspects of the limb, meeting upon its inner border 
on a level with the lowest part of the vertical incision (Fig. 335, C). 

Operation. — (i) The vertical incision passes at once through the deltoid 
directly to the bone and into the joint. The operation, which may have 
been begun as an exploratory one, may end with an investigation of the joint 
— or may proceed to an excision of the joint structures — or may end as an 
amputation. If the latter, the oval, or racket, incision, as above described, 
is added to the vertical incision. (2) The limbs of the racket are at first 
incised through skin and fascia only, and may be made at one stroke, or, 
better, by two. (3) The anterior limb of the racket is now deepened, while 
the arm is rotated outward — the incision passing through the anterior portion 
of the deltoid — the tendon of the pectoralis major is severed as near the 
bone as possible — the coracobrachialis and biceps are divided — and, next to 
these, the axillary vessels are encountered, carefully exposed and doubly 
ligated, beyond the posterior circumflex branch. This flap is then freed 
up to the joint. For the same reasons mentioned under the last operation, 
the freeing of these flaps should be done as subperiosteally as possible. (4) 
The posterior limb of the racket is similarly deepened, the arm being rotated 
inward — the incision passing through the posterior portion of the deltoid — 
and meeting the anterior limb upon the inner side of the arm. This flap 
is then also freed up to the joint as subperiosteally as possible. (5) Dis- 
articulation is accomplished (after severing close to the bone in the above 
freeing of the anterior and posterior flaps, the attachments of the supra- 
spinatus, infraspinatus, and teres minor to the great tuberosity, and the 
subscapularis to the lesser) by cutting the capsule and the long head of the 
biceps against the head of the bone transversely. The head of the bone is 
now disarticulated and thrust upward. (6) To sever the remaining soft 
parts, the surgeon grasps the disarticulated head of the humerus with his 
left hand and draws it outward — then inserts a long knife between the neck 
of the bone and the remaining undivided parts, and, by a sawing movement, 
cuts his way downward and outward between the severed axillary vessels 
and the bone, coming out on a line with the retracted inner limb of the racket 
incision (just as in the disarticulation by the anterior racket). (7) Besides 
the above-named vessels, the anterior and posterior circumflex are both apt 
to be divided, as well as some muscular branches. The circumflex nerve is 
likely to be severed. All nerves are cut short. (8) The capsule is to be 
trimmed, if hanging in tags. Temporary drainage is used. The capsulo- 



382 AMPUTATIONS. 

periosteal, or capsulo-muscular covering is sutured — the muscles quilted 
deeply and superficially — and the skin sutured in a vertical line. 

Comment. — This operation is an illustration of the control of hemor- 
rhage by the ligation of the main vessels in the line of incision, prior to dis- 
articulation. 

DISARTICULATION AT SHOULDER- JOINT 

PA' EXTERNAL OR DELTOID FLAP. 

Description. — A U-shaped flap, consisting practically of the deltoid 
muscle, is raised from the outer side of the shoulder — its upper limits being 
connected by a transversely curved incision across the inner aspect of the 
arm. 

Position.— As in Spence's operation (page 378). 

Landmarks. — Coracoid process of scapula; spine of scapula. 

Incision. — The base of this U-shaped flap extends from the coracoid 
process, anteriorly, to the spine of the scapula at the root of the acromion 
posteriorly. In length, the flap extends nearly to the insertion of the deltoid. 
The upper extremities of the limbs of the flap are joined by a transversely 
curved incision (with slight downward convexity) crossing the inner side 
of the arm about 5 cm. (2 inches) below the lower limit of the axilla. On 
the right side, the incision begins at the root of the acromion and ends at the 
coracoid, the arm having been placed across the chest. On the left side, 
the incision begins at the coracoid, with the arm abducted — and ends at the 
root of the acromion, with the arm across the chest. In both, the surgeon 
manipulates the limb with his left hand. This flap consists of the entire 
thickness of the deltoid at the base, while its margins are beveled. (Fig. 335, 
D, D.) 

Operation. — The entire length of the superficial incision outlining the 
flap is now deepened to the bone along the line of the retracted skin — cutting 
in a beveling fashion obliquely from without inward and from below upward. 
This mass of soft tissues is then raised from the bone, severing the attach- 
ments of the muscles of the great and less tuberosities. The joint is now 
opened by cutting directly down upon the capsule and long head of the biceps 
transversely against the head of the bone. The head of the bone is dis- 
articulated and thrust upward, and the operation completed as in Spence's 
method of disarticulating — that is, the head of the bone is grasped and drawn 
outward — an assistant guarding the tissues of the inner flap as in the opera- 
tion just mentioned, a long knife is inserted between the neck of the bone 
and the still undivided tissues upon the inner aspect and made to cut its way 
downward and outward on a line with the transversely curved portion of the 
incision connecting the upper limbs of the flap, thus severing the pectoralis 
major, latissimus dorsi, and teres major. Having ligated the vessels and 
cut the nerves short — the muscles are quilted — and the integumentary margin 
of the deltoid flap is sutured to the border of the short internal flap. 

Comment. — (1) This is the least desirable of the three methods of dis- 
articulation described. (2) Hemorrhage may be controlled by some form 
of tourniquet, or by the early ligation of the artery in the axilla. (3) An 
attempt may be made to save the circumflex nerve and the posterior circumflex 
artery — either by isolating and retracting them while incising from the skin 
downward in the posterior limb of the flap — or by approaching them from 
the anterior portion of the flap, working under the periosteum and then 
retracting them. 



INTERSCAPULO-THORACIC AMPUTATION. 383 



AMPUTATION OF UPPER LIMB, TOGETHER WITH SCAPULA AND 
PART OF CLAVICLE, 

BY ANTEROINFERIOR (OR PECTORO-AXILLARY) AND POSTERO-SITERIOR (OR 
CERVICO-SCAPULAR) FLAPS— BERGER'S OPERATION. 

Description. — Consists in the removal of the upper limb, together with 
the scapula and the outer two-thirds of the clavicle, en masse, without dis- 
articulation at the shoulder-joint. 

Position. — Given in the steps of the operation. 

Landmarks. — Outline of clavicle; outline of scapula; line of shoulder- 
joint articulation. 

Operation.— (1) Subperiosteal Excision of middle third of Clavicle and 
double ligature and division of Subclavian Artery and Vein: — Patient on 
back, at edge of table; shoulders raised; arm by side. Make an incision 
through the periosteum to bone, over the upper surface of the clavicle, from 
outer border of sternomastoid to just beyond the acromioclavicular articu- 
lation (Fig. 341, C, C, C). The vein from the cephalic to the external jugular 
is hereby cut and is doubly ligated. The periosteum is raised, with curved 
periosteal elevator, from around the entire circumference of the middle third 
of the clavicle. A chain or Gigli saw is passed between bone and periosteum 
and the clavicle is divided at the junction of its inner and middle thirds. 
The outer two-thirds of the clavicle is now grasped with lion-jaw forceps 
and drawn outward, during which outward traction whatever periosteum 
may remain is now detached from its middle third. The clavicle is then 
sawed at the junction of the middle and outer thirds, by a chain, Gigli, or 
small saw. The middle third of the clavicle is thereby removed. The 
periosteum over the subclavius muscle and the subclavius muscle are 
now divided transversely, opposite the inner section of the clavicle, and 
are dissected up and turned outward, thereby exposing the subclavian 
vessels, surrounded by more or less fascia. Having divided the over- 
lying fascia, the subclavian vein and then the artery are exposed. Both 
artery and vein are doubly ligated and divided opposite the lower 
border of the first rib — the former being secured first (to lessen the 
amount of blood left in the limb). (2) Formation of Anteroinferior (or 
Pectoro-axillary) Flap: — Patient on back, with shoulder over edge of table; 
arm abducted; head to opposite side. Surgeon between arm and trunk. 
The incision begins at the middle of the clavicular incision — curves down- 
ward and outward, passing close to the outer side of the coracoid process — 
thence along the anterior portion of the deltoid, just external to the pectoro- 
deltoid groove, to the junction of the anterior axillary wall with the arm — 
thence across the lower border of the pectoralis major — thence transversely 
across the inner or axillary surface of the arm — to the lower borders of the 
tendons of the latissimus dorsi and teres major. Here the limb is elevated — 
and the incision is earned downward and inward in the groove between 
the vertical border of the scapula and the muscular elevation formed by 
the teres major and latissimus dorsi, to end over the posterior surface of the 
inferior angle of the scapula. This incision passes, at first, through skin 
and fascia, and is then deepened through the pectoral and axillary tissues 
— the pectoralis major being cut where its tendinous portion commences — 
the pectoralis minor near the coracoid process — the brachial plexus near the 
first rib — the latissimus dorsi in the more posterior part of the line of incision 
— and whatever remaining axillary tissues bind the limb are cut as encoun- 
tered. The shoulder is thus freed from the trunk anteriorly — and tends to 



384 AMPUTATIONS. 

fall outward and backward. (3) Formation of the Postero-superior (or 
Cervico-scapular) Flap: — The patient is still supine, with shoulder over 
edge of table; the arm is now drawn across the chest to emphasize the scapular 
region. The surgeon stands to the outer side. The incision begins at the 
outer end of the clavicular incision, just external to the acromio-clavicular 
joint — passing thence backward over the spine of the scapula by the shortest 
route, to join the lower end of the antero-inferior flap incision over the inferior 
angle of the scapula. This incision at first involves only the skin and fascia, 
which are then well retracted along their upper part, thus exposing the trape- 
zius, which is now divided near its attachment to the clavicle and scapula, 
and thus severed from the whole limb. (4) Severing of Connections of 
Scapula to Trunk: — The patient lies as in the last step — and the surgeon 
stands to the inner side of the right and outer side of left limb. The anterior 
and posterior flaps are well retracted and the limb permitted to hang away 
from the side. The superior and vertical borders of the scapula are rendered 
prominent and are now freed by cutting the following muscles close to the 
bone, in order from above downward: omohyoid, levator anguli scapula 1 , 
rhomboideus minor, rhomboideus major, and serratus magnus. The upper 
extremity is now free from the trunk — the muscles arising from the scapula 
and inserted into the humerus (teres major and minor, subscapulars, supra- 
spinatus, and infraspinatus) are removed untouched with the limb. (5) Con- 
trol of Hemorrhage: — Preliminary ligation of the subclavian artery and vein 
control the chief hemorrhage. In forming the anterior flap, branches of 
the acromio-thoracic, long thoracic and subscapular are encountered. In 
forming the posterior flap, the muscular branches in the trapezius are met. 
In severing the scapula the chief bleeding occurs — the suprascapular artery 
is to be tied near the omohyoid as it is about to enter the supraspinous fossa 
— and the posterior scapular is to be tied near the upper angle of the scapula 
just after dividing the levator anguli scapulae. (6) Closure of the Wound: — 
All the nerves are divided short. Generally no sufficient redundancy of mus- 
cles is present to admit of quilting, it usually being difficult to approximate 
the edges of the wound — but, if it be possible, quilting of the muscles together 
with buried gut sutures should be done — to make a thicker stump-padding 
and to take the strain off the cutaneous sutures. The anterior and posterior 
flaps are brought together and sutured in one oblique line, extending from 
above, downward, outward, and backward. To obliterate the dead spaces 
which tend to form in so extensive a wound, considerable even pressure is 
applied in the dressings which bind the parts to the thorax. No drainage 
is indicated in simple cases. 

Comment. — (1) Sometimes the outer two-thirds of the clavicle is drawn 
outward and disarticulated at the acromion. (2) If the suprascapular and 
posterior scapular arteries are ligated through such a wound as is made 
in exposing the clavicle, at this stage, the chief bleeding of the whole operation 
will be avoided. The former is easily found. (3) One is apt to find too 
scanty an allowance of flap covering, which is caused by not extending the 
oval parts of the incisions far enough out over the shoulder. 



SURFACE FORM AND LANDMARKS OF TOES. 385 

AMPUTATIONS AND DISARTICULATIONS OF THE LOWER 

EXTREMITY. 

SURGICAL ANATOMY OF THE TOES. 

Bones. — Third, second, and first Phalanges. 

Articulations and Ligaments. — (a) Second and Third Interphalangeal 
Joint: — Plantar; dorsal and two lateral ligaments. Extensor tendon rein- 
forces dorsal aspect of joint, (b) First and Second Interphalangeal Joint: — 
Same as last, (c) Metatarsophalangeal Joints: — Plantar (glenoid), dorsal, 
and two lateral ligaments. Extensor tendon reinforces dorsal aspect. 

Muscles. — See under Foot (page 397). 

Sheaths of Flexor Tendons. — Tendons of flexor longus digitorum and 
flexor brevis digitorum, in their passage along the phalanges, are bound 
against the bones by fibrous sheaths attached to margins of phalanges and 
forming osseo-aponeurotic ca